| Renal Care Matters | W.G.M. Rivero MD · FPCP · DPSN |
| Population / decision | KDIGO 2026 guidance |
|---|---|
| Anemia + hemodialysis (HD): initiate iron | Ferritin ≤500 ng/mL and TSAT ≤30%. IV iron is suggested; use a proactive, monitored approach. |
| Anemia + non-dialysis CKD or peritoneal dialysis (PD): initiate iron | Ferritin <100 ng/mL and TSAT <40%, or ferritin ≥100 and <300 ng/mL and TSAT <25%. |
| Route outside HD | Choose oral or IV iron using severity, response, tolerance, preference, availability, and cost. Switch an optimal oral regimen to IV if ineffective after 1–3 months or poorly tolerated. |
| Withhold routine iron | Ferritin >700 ng/mL or TSAT ≥40%. An elevated ferritin alone does not diagnose iron overload. |
| Systemic infection | Consider temporarily suspending iron. Inflammation without infection needs clinical assessment rather than an automatic infection diagnosis. |
| Monitoring during iron treatment | Hb, ferritin, TSAT every 3 months in non-dialysis CKD/PD; every 1–3 months in HD, often monthly. Test sooner after blood loss, hospitalization, ESA escalation, or rapidly changing iron indices. |
Confirm anemia and evaluate symptoms, bleeding, infection, iron exposure, and reversible causes. Ferritin can rise with inflammation. A high ferritin alone does not establish iron overload. Respect formulation-specific dose and infusion limits.
Source: KDIGO 2026 Anemia in CKD, Kidney International 109 (Suppl 1S), S1–S99. renalcarematters.com · Reviewed November 6, 2026.
| Renal Care Matters | W.G.M. Rivero MD · FPCP · DPSN |
| Decision | KDIGO 2026 guidance |
|---|---|
| Adult HD or PD: consider initiation | After reversible causes are addressed, consider ESA when Hb is ≤9–10 g/dL. Select the threshold within that range using symptoms, risks, and patient preferences. |
| Non-dialysis CKD, including transplant recipients | Individualize initiation using symptoms, potential benefit, transfusion avoidance, ESA risks, and preferences; Hb <10 alone is not an automatic start order. |
| Adult maintenance goal | Target Hb below 11.5 g/dL (115 g/L), individualized. A common working range is about 10 to <11.5 g/dL; this is not an anemia diagnostic range. |
| Dose changes | Use the lowest effective dose. Generally avoid adjustments more often than every 4 weeks. If Hb rises >1 g/dL in 2–4 weeks, reduce by 25–50%. Prefer reduction to holding while Hb does not exceed 11.5, as clinically appropriate. |
| Monitoring | Hb every 2–4 weeks after initiation or adjustment; at least every 3 months during maintenance, usually more often in HD. |
| Stroke, thrombosis, and cancer | Consider suspending ESA during hospitalization for acute stroke, vascular access thrombosis, or thromboembolism. Active or previous cancer calls for shared decision-making, especially when treatment aims at cure. Uncontrolled hypertension and product-specific contraindications require review. |
Date: __________ Patient: ____________________ Symptoms / bleeding / infection: ____________________
Hb: ______ g/dL Previous Hb/date: ______________ TSAT: ______ % Ferritin: ______ ng/mL
ESA / native dose / interval: __________________ Last change: __________ Iron formulation / exposure: __________________
BP / dialysis adequacy / nutrition / reversible causes: _______________________________________
Plan, reason, and next laboratory review: __________________________________________________
Trend ERI; no universal KDIGO cutoff of 10 or 14. Do not combine ESA and HIF-PHI. HIF-PHI trials in hyporesponsiveness require discussion of limited evidence and discontinuation after 3–4 months without the desired response. For chronic CKD anemia, transfusion decisions are based on symptoms and signs rather than an arbitrary Hb threshold.
Source: KDIGO 2026 Anemia in CKD, Kidney International 109 (Suppl 1S), S1–S99. renalcarematters.com · Reviewed November 6, 2026.