Uncertainty exists over the optimal treatment for iron deficiency in CKD patients.1 The potential risks of iron supplementation should be weighed against the possible benefits of avoiding or limiting blood transfusions, erythropoietin stimulating agent (ESA) therapy, and anemia-related symptoms. 1

KDIGO Guidelines

ERBP Guidelines

Recommendation for adult patients with CKD and anemia.1

Trial of iron if the TSAT is ≤30% and serum ferritin is ≤500 ng/mL

Trial of iron if the TSAT is <20% and serum ferritin is <100 ng/mL

Goal during

Remain below TSAT of 30% and ferritin of 500 ng/mL

TSAT, transferrin saturation; KDIGO, Kidney Disease: Improving Global Standards; ERBP, European Renal Best Practice

  • The NICE (National Institute for Health and Care Excellence) 2015 Guidelines and the Renal Association 2017 Guidelines have increased the ceiling of ferritin to 800 ng/mL during supplementation.1
  • Iron supplementation is available via the oral or IV route. A trial of iron for 1 to 3 months is recommended in patients with anemia and NDD CKD.2
  • Oral iron may be used, if tolerated, in patients with NDD-CKD.2
  • IV iron has a safety profile comparable to that of oral iron, with more infusion reactions and fewer gastrointestinal side effects.2
  • Ferric carboxymaltose is a newer IV iron preparation given at a dose of 500 mg to 1000mg once or twice per week and is approved for the first-line treatment of adults with NDD-CKD.2
  • The benefit of IV iron outweighs the risks in CKD, and IV iron is preferred in patients with NDD-CKD.2
Key Points: Treatments and Modulators1

ESA/Exogenous EPO


HIF-PHD Inhibitors

EPO, erythropoietin; ESA, erythropoietin stimulating agent; PHD, prolyl hydroxylase domain-containing proteins; HIF, hypoxia-inducable factor

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  1. Batchelor EK, Kapitsinou P, Pergola PE, et al. Iron Deciency in Chronic Kidney Disease: Updates on Pathophysiology, Diagnosis, and Treatment. J Am Soc Nephrol. 2020;31(3):456-468. doi: 10.1681/ASN.2019020213. Epub 2020.
  2. Gafter-Gvili A, Schechter A, Rozen-Zvi B. Iron Deciency Anemia in Chronic Kidney Disease. Acta Haematol. 2019;142(1):44-50. doi: 10.1159/000496492. Epub 2019.