New anemia guideline backs personalized treatment, favors IV iron in dialysis

Clinical takeaway: Before starting anemia drugs in CKD, address reversible causes such as iron deficiency, use IV iron as the preferred option in hemodialysis patients, and tailor ESA initiation to symptoms, cardiovascular risk, transplant candidacy, and patient preferences.

The Kidney Disease: Improving Global Outcomes (KDIGO) 2026 guideline updates the society's 2012 recommendations on anemia management in chronic kidney disease (CKD), reflecting new evidence on iron therapy, erythropoiesis-stimulating agents (ESAs), and hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). The guideline, based on evidence reviewed through October 2024, places greater emphasis on individualized treatment decisions rather than fixed hemoglobin targets or medication thresholds.

A major shift is stronger support for proactive IV iron use in patients receiving hemodialysis. KDIGO suggests initiating iron when ferritin is ≤500 ng/mL and transferrin saturation (TSAT) is ≤30%, with IV iron preferred over oral formulations in this population. The recommendation is informed largely by the PIVOTAL trial, which found that a proactive IV iron strategy reduced cardiovascular events, transfusions, and ESA requirements without increasing infections or other serious adverse events.

For patients with CKD who are not receiving hemodialysis, the approach is more individualized. Iron therapy is suggested based on ferritin and TSAT thresholds, but clinicians may choose either oral or IV iron depending on anemia severity, tolerability, availability, cost, and patient preference.

Another key recommendation concerns anemia medications. After correctable causes of anemia have been addressed, KDIGO suggests ESAs rather than HIF-PHIs as first-line therapy. Although HIF-PHIs generally achieve hemoglobin increases comparable to ESAs, the guideline notes ongoing uncertainty about their long-term cardiovascular and safety profile, particularly in patients not receiving dialysis.

The guideline also personalizes hemoglobin thresholds for ESA initiation. In dialysis patients, ESA therapy is generally recommended when hemoglobin falls to 9 to 10 g/dL or lower. In non-dialysis CKD, no single threshold is endorsed; clinicians should consider anemia symptoms, potential benefits of higher hemoglobin levels, risks of ESA therapy, and the desire to avoid transfusions.

Importantly, KDIGO continues to caution against normalization of hemoglobin levels. For adults receiving ESA therapy, the guideline recommends maintaining hemoglobin below 11.5 g/dL, citing evidence that higher targets increase the risk for hypertension, thrombotic complications, and cardiovascular events.

As the authors write, the update “underscores the necessity of personalizing treatment to individual patient characteristics and preferences to minimize the risks and maximize the benefits of treatments offered for anemia.”

What's changed

• Greater emphasis on individualized anemia management rather than uniform treatment thresholds.
• IV iron is now the preferred route of iron replacement for patients receiving hemodialysis.
• More proactive iron treatment is supported in hemodialysis patients, using ferritin and TSAT to guide therapy.
• ESAs are recommended over HIF-PHIs as first-line drug therapy after reversible causes of anemia have been corrected.
• ESA initiation should consider symptoms, cardiovascular risk, transplant candidacy, and patient preferences, especially in non-dialysis CKD.
• Hemoglobin should generally be maintained below 11.5 g/dL during ESA treatment.
• New terminology distinguishes “systemic iron deficiency” from “iron-restricted erythropoiesis.”

Source: Hedayati SS, et al. (2026 Sep 14) Ann Intern Med. Evaluation and Management of Anemia in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2026 Clinical Practice Guideline