Kidney Disease: Improving Global Outcomes (KDIGO) recently released an update to its 2012 guideline on the management of anemia in chronic kidney disease (CKD). The guideline update followed a literature search conducted in October of 2024 and is designed to support healthcare providers in evaluating and managing anemia across CKD stages in adults and children.

The KDIGO clinical practice guideline features chapters on the evaluation and diagnosis of CKD, iron management, the initiation and monitoring of ESAs and HIF-PHIs, and the role of red blood cell transfusions. In addition to recommendations featured in each chapter (outlined below), each chapter has practice points that are ungraded, consensus-based statements.

In total there are 48 practice points, with the bulk of them appearing in chapters two and three. Consult the full-text version of the KDIGO 2026 clinical practice guideline on the management of anemia in CKD for a look at all the practice points alongside a more thorough look at each recommendation. 

Key Recommendations Included in the 2026 Update

Chapter 1 – Diagnosis and Evaluation of Anemia in People with Chronic Kidney Disease

No recommendations provided. 

Chapter 2 – Use of Iron to Treat Iron Deficiency and Anemia in People with Chronic Kidney Disease

Four recommendations provided:

  • 2.1: In people with anemia and CKD G5 receiving hemodialysis (CKD G5HD), we suggest initiating iron therapy if ferritin £500 ng/ml (£500 mg/l) and TSAT £30%.
  • 2.2: In people with anemia and CKD G5HD who are initiating iron therapy, we suggest using intravenous (i.v.) iron rather than oral iron. 
  • 2.3: In people with anemia and CKD not receiving dialysis or CKD G5 receiving peritoneal dialysis (CKD G5PD), we suggest initiating iron if: Ferritin <100 ng/ml (<100 mg/l) and TSAT <40% or Ferritin ‡100 ng/ml (‡100 mg/l) and <300 ng/ml (<300 mg/l), and TSAT <25%.
  • 2.4: In people with anemia and CKD not receiving hemodialysis (HD) in whom iron is initiated, we suggest using either oral iron or i.v. iron based on the person’s values and preferences, the degree of anemia and iron deficiency, and the relative ef cacy, tolerability, availability, and cost of each.

Chapter 3 – Use of Erythropoiesis-stimulating Agents, Hypoxia-inducible Factor-prolyl Hydroxylase Inhibitors, and Other Agents to Treat Anemia in People with Chronic Kidney Disease

Four recommendations provided:

  • 3.1.1:  In people with anemia and CKD in whom correctable causes of anemia have been addressed, we suggest using an ESA rather than a HIF-PHI as first-line treatment of anemia.
  • 3.2.1: In people with anemia and CKD G5D receiving HD or peritoneal dialysis, we suggest initiation of ESA therapy when the Hb concentration is £9.0–10.0 g/dl (£90–100 g/l).
  • 3.2.2: In people with CKD not receiving dialysis, including kidney transplant recipients and children, the selection of Hb concentration at which ESA therapy is initiated should consider the presence of symptoms attributable to anemia, the potential bene ts of higher Hb concentration, and the potential harms of RBC transfusions or ESA therapy.
  • 3.3.1: In adults with anemia and CKD treated with ESAs, we recommend targeting the Hb level to below 11.5 g/dl (115 g/l).

Chapter 4 – Red Blood Cell Transfusions to Treat Anemia in People with Chronic Kidney Disease

No recommendations provided.

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