New guidance emphasizes regular anemia and iron deficiency screening, individualized treatment, careful use of iron therapy and ESAs, and avoiding excessive hemoglobin correction
Kidney Disease: Improving Global Outcomes (KDIGO) has released updated clinical practice guidance for the management of anemia in patients with chronic kidney disease (CKD), more than a decade after its previous guideline. The 2026 update addresses anemia screening, iron deficiency, iron supplementation, erythropoiesis-stimulating agents (ESAs), and newer treatment options for CKD-associated anemia.
Published in Kidney International in January 2026, the updated guidance combines recommendations based on systematic reviews with additional practice points derived from expert opinion. The guideline authors noted that evidence remains limited in several areas, with a number of recommendations supported by low- or very-low-certainty evidence.
The updated guidance emphasizes regular laboratory monitoring to detect anemia and iron deficiency. It also recommends that treatment decisions be individualized according to dialysis status, symptoms, treatment-related risks, and the patient’s response to therapy.
Regular Screening Recommended for CKD-Associated Anemia
KDIGO recommends that patients with CKD undergo regular assessment for anemia using a complete blood count, reticulocyte count, ferritin, and transferrin saturation (TSAT).
The recommended screening frequency is at least once a year for patients with stage 3 CKD, twice a year for those with stage 4 CKD, and every three months for patients with stage 5 CKD.
Anemia continues to be defined as a hemoglobin level below 12 g/dL in women and below 13 g/dL in men. Age-specific thresholds apply to children younger than 15 years.
Evaluation for Possible Blood Loss
The updated guidance recommends considering an evaluation for potential sources of blood loss when ferritin levels are below 45 ng/mL or when microcytic anemia is present.
This assessment is intended to help identify potentially treatable causes contributing to anemia and iron deficiency.
Iron Therapy Recommendations Differ by Dialysis Status
For patients receiving hemodialysis, iron therapy should be considered when ferritin is 500 ng/mL or lower and TSAT is 30% or lower. Intravenous iron is preferred in this setting, although KDIGO notes that the supporting evidence has very low certainty.
For patients with CKD who are not receiving dialysis, iron therapy may be considered when ferritin is below 100 ng/mL with TSAT below 40%, or when ferritin is between 100 and 300 ng/mL with TSAT below 25%.
KDIGO also recommends regular monitoring during iron treatment. In patients receiving hemodialysis, CBC, ferritin, and TSAT should generally be checked every one to three months. For patients not receiving dialysis, monitoring is recommended approximately every three months.
Iron Therapy May Need to Be Paused During Systemic Infection
The guidance advises clinicians to consider temporarily discontinuing iron therapy if a patient develops a systemic infection.
The recommendation reflects the need to reassess treatment during acute illness and consider the potential risks and benefits of continuing iron supplementation.
ESAs May Be Considered During Dialysis
For patients receiving hemodialysis or peritoneal dialysis, erythropoiesis-stimulating agents may be considered when hemoglobin levels fall to approximately 9–10 g/dL.
The updated guidance favors ESAs over hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, although KDIGO states that the certainty of evidence supporting this recommendation is very low.
For patients with CKD who are not receiving dialysis, decisions regarding anemia medications should take into account symptoms and the potential balance between treatment benefits and harms.
KDIGO Advises Against Excessive Hemoglobin Correction
The updated guidance recommends avoiding excessive correction of anemia. When medications are used to treat anemia, hemoglobin should generally be maintained below 11.5 g/dL because higher hemoglobin levels may increase the risk of stroke.
KDIGO also recommends reassessing ESA therapy during hospitalizations or clinical situations associated with increased thromboembolic risk. Temporary interruption of ESA treatment may be considered in high-risk situations, including an acute stroke.
Individualized Treatment Remains Central to Anemia Management
The 2026 KDIGO guidance provides a framework for managing anemia, a common complication of CKD, but emphasizes that recommendations should not be applied without clinical judgment.
Several recommendations are supported by low- or very-low-certainty evidence, while some practice points are based on expert opinion. Therefore, treatment decisions should take into account individual patient characteristics, symptoms, dialysis status, laboratory trends, treatment response, and potential risks.
The updated guidance may help clinicians adopt a more systematic approach to anemia screening and iron assessment while balancing the potential benefits of treatment against unnecessary iron supplementation and the risks associated with excessive hemoglobin correction.
Important Highlights
- KDIGO has released updated 2026 guidance for managing anemia associated with chronic kidney disease.
- CKD patients should undergo regular assessment using CBC, reticulocyte count, ferritin, and TSAT.
- Iron therapy recommendations differ depending on whether a patient is receiving dialysis.
- ESAs may be considered during hemodialysis or peritoneal dialysis when hemoglobin falls to approximately 9–10 g/dL.
- Hemoglobin should generally be maintained below 11.5 g/dL when anemia medications are used.
- Several recommendations are based on low- or very-low-certainty evidence, highlighting the importance of individualized clinical decision-making.
