KDIGO 2026 Clinical Practice Guideline for Anemia in Chronic Kidney Disease (CKD): a commentary from the European Renal Best Practice (ERBP)
ERA · 2026 · Europe
Source and licence
- Authors
- Lucia Del Vecchio, Aleix Cases, Michele F Eisenga et al.
- Title
- KDIGO 2026 Clinical Practice Guideline for Anemia in Chronic Kidney Disease (CKD): a commentary from the European Renal Best Practice (ERBP)
- Journal
- Nephrology Dialysis Transplantation, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13423824
Licence statement of the original publication
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
USE OF IRON TO TREAT IRON DEFICIENCY AND ANAEMIA IN CKD
- Recommendation 2.3proposes initiating iron therapy in NDD-CKD or peritoneal dialysis patients when ferritin is <100 ng/mL and TSAT <40%, or when ferritin is between 100–299 ng/mL with TSAT <25%. We support these thresholds, as they align with a more proactive iron strategy and represent a clear departure from the more conservative suggestions of the position paper of the ERBP of 2013 for the European population [25]. In fact, the FIND-CKD trial showed the superiority of IV iron targeting serum ferritin levels of 400–600 ng/mL unless TSAT was ≥40% in increasing Hb levels and serum ferritin vs oral iron, and reducing the need for other anaemia therapies, including ESAs [3]. Nevertheless, we would like to raise some concerns regarding the upper TSAT cut-off of 40%, which has been selected in alignment with ferritin <100 ng/mL. The optimal TSAT level for maximizing the Hb response to ESAs appears to be around 30% [26], casting doubt on the necessity of starting iron therapy in patients with ferritin just under 100 ng/mL and a TSAT, for example, of 35%. On the other hand, recent observational data suggest that TSAT levels between 30% and 40% may be associated with better clinical outcomes than levels around 30%. For instance, Nakai et al. [27] found that Japanese HD patients with TSAT between 30% and 40% experienced significantly fewer cardiovascular events than those with TSAT between 20% and 30%, particularly among those receiving long-acting ESAs. Similarly, Guedes et al. [28] demonstrated that ID, as captured by TSAT, is associated with higher risks of all-cause mortality and major adverse cardiovascular events (MACE) in NDD-CKD, regardless of the anaemic status [28]. A spline analysis indicated that the lowest risk occurred at a TSAT of 40%. These findings support initiating iron therapy in patients with TSAT <40%, particularly when serum ferritin is low. A small, short-term randomized controlled trial (RCT) of 46 HD patients, who were randomized to receive IV iron to a TSAT target of 20%–30% or 30%–50%, demonstrated a 30% decrease in ESA dose in the higher TSAT target group [29]. However, differences of mean TSAT across groups were low (27.2%–24.5%) in the control group vs (31.1%–34.9%) in the active group. Given that TSAT reflects iron availability, it is more acutely affected by recent iron administration than ferritin. In this respect, most observational studies do not report the timing of TSAT measurement relative to iron supplementation. For example, the FIND-CKD [3] trial discontinued oral iron one week before inclusion, but did not provide details on prior iron use in the enrolled population. In the opinion of the ERBP working group, these results are insufficient to support a target TSAT >40% which may perhaps expose patients to the risk of iron accumulation with time [29].
- Recommendation 2.4, which leaves the choice between oral and IV iron to patient preference in NDD-CKD, is appropriate. But in case that a trial with oral iron is ineffective in increasing Hb levels after 1–3 months or in cases of intolerance, patients should be shifted to IV iron, as recommended in practice point 2.7.
- Practice Point 2.2suggests withholding iron in CKD patients when ferritin is ≥700 ng/mL or TSAT is ≥40% without differentiating CKD populations. These thresholds are primarily based on the PIVOTAL study protocol [5]. Given the outcomes of PIVOTAL and other trials in HD patients, these thresholds appear reasonable for that population. However, it is questionable whether this approach should be generalized to NDD-CKD patients without further supporting evidence. In addition, the PIVOTAL trial compared proactive and reactive approaches rather than specific ferritin or TSAT targets. Therefore, these results do not imply that maintaining ferritin levels between 200 and 700 ng/mL (e.g. 400 ng/mL) is inferior to the proactive strategy. In NDD-CKD, the largest relevant study is the FIND-CKD trial [3], which allowed a maximum ferritin level of 600 ng/mL and recommended withholding iron when TSAT was ≥40%. This RCT focused on intermediate markers with a relatively short follow-up to demonstrate long-term benefits. Hence, future RCTs should prioritize outcomes like fatigue, transfusion avoidance, hospitalizations and cardiovascular events. From a methodological point of view, targeting serum ferritin levels of 400–600 ng/mL seems reasonable in the NDD-CKD population, despite the above limitations.
Treatment initiation and ESA maintenance therapy
- Practice Point 3.4.3.2suggest monitoring Hb every 2–4 weeks during treatment with ESA or HIF-PHI and adjust the dose accordingly to avoid a rapid rise of >1.0 g/dL during that interval. This was meant for detecting rapid rises in Hb and preventing overshooting Hb targets. In our opinion, monitoring Hb every 2 weeks is unnecessary in most cases in everyday clinical practice, especially for NDD-CKD patients, also considering that early dose changes should be avoided as the practice point recommends. Furthermore, a rise in Hb >1 g/dL but lower than 2 g/dL at 4 weeks is considered adequate. Therefore, we consider more appropriate avoiding Hb increases >2 g/dL in 4 weeks as a more precise suggestion.
Abstract
The 2026 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in Chronic Kidney Disease represents a substantial update, coming more than a decade since the previous KDIGO guideline on the topic. This time lapse was necessary in order to accumulate new scientific evidence that was meaningful for an updated guideline. The new guideline now includes updated recommendations and practice points for anaemia management, incorporating recent evidence on intravenous iron therapies and hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). This European Renal Best Practice commentary critically evaluates and comments on relevant and newer recommendations and practice points, focusing on key aspects from a European perspective. The new guideline emphasizes the need for a comprehensive evaluation of the patient at the time of diagnosis, to identify additional causes of anaemia other than erythropoietin insufficiency. Coherently, the timing and the type of treatment should be individualized. Moreover, it introduces more proactive thresholds for intravenous iron supplementation, especially for haemodialysis patients. Erythropoiesis-stimulating agents are recommended as the preferred first-line therapy due to persisting concerns regarding cardiovascular safety and methodological limitations of available HIF-PHI trials. The commentary includes considerations on special aspects not considered by the new KDIGO guideline, such as pregnancy, gender-specific considerations, and interactions with sodium-glucose cotransporter 2 inhibitors or inflammation. The commentary also highlights regional regulatory differences between European and US drug approvals for HIF-PHIs. While supporting most recommendations, European nephrologists should consider local contexts, regulatory approvals and emerging evidence when implementing these guidelines in clinical practice.
Contents of the original publication
The section headings of the original.
- INTRODUCTION
- DIAGNOSIS AND EVALUATION OF ANAEMIA IN CKD
- USE OF IRON TO TREAT IRON DEFICIENCY AND ANAEMIA IN CKD
- USE OF ESAs, HIF-PHIs AND OTHER AGENTS TO TREAT ANAEMIA IN CKD
- Treatment initiation and ESA maintenance therapy
- HIF-PHI treatment initiation and maintenance
- HIF-PHI monitoring
- ESA hyporesponsiveness
- RBC TRANSFUSIONS
- MISSING POINTS
- Anaemia diagnosis and treatment across genders
- Special considerations for pregnancy
- SGLT2 inhibitors, anaemia and erythrocytosis
- Anaemia of CKD and anti-inflammatory drugs
- CONCLUDING REMARKS
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