Iron-Deficiency Anemia in Non-Dialysis – Dependent CKD: Guidelines

Iron-Deficiency Anemia in Non-Dialysis – Dependent CKD: Guidelines

KDIGO (Kidney Disease:Improving Global Outcomes) are developing an update to  their 2012 Clinical Practice Guideline for Anemia in Chronic Kidney Disease (CKD). The guideline is intended to be used by a broad group of patients with CKD and anemia.  Its objective is to produce a valuable resource for clinicians offering useful recommendations, based on a thorough examination of available evidence,  complemented by practice points and infographics. The new guideline will also aim to  propose research recommendations for areas where there are gaps in knowledge.1 


Clinical practice recommendations for managing anemia in CKD have been historically contradictory and perceived to be influenced by industry. The publication of the 2012 KDIGO guideline that updated and informed clinical practice in this area was therefore welcomed.2

The 2012 KDIGO Clinical Practice Guideline for Anemia in CKD was developed to enhance the care and outcomes of patients with CKD around the globe.3 The 2012 guidelines provide comprehensive evidence-based recommendations to aid  clinicians.3 The main difference in the 2012 KDIGO guidelines compared to previous guidance is the use of the lowest dose of erythropoiesis-stimulating agent (ESA) to prevent blood transfusions and the abandonment of Hb concentration targets.4 There  are 47 recommendations in the KDIGO guideline, all with differing degrees of supporting data.2

While intravenous (IV) iron is useful in the setting of iron deficiency, IV iron may be associated with some risks.2 The KDOQI (Kidney Disease Outcomes Quality Initiative) commentary on the guidelines states the degree of caution expressed by KDIGO, around IV iron, is not supported by the available evidence.2 For children and adults, KDOQI supports individualizing therapy to treat anemia in patients with CKD.4 It is  noteworthy that the KDIGO guidelines emphasize weighing the advantages and  disadvantages of iron therapy with ESAs.2

The evidence suggests that patients with CKD should aim for hemoglobin (Hb) target  values between 10 and 11.5 g/dL rather than levels >13 g/dL, which have the potential  to be harmful.2 The KDIGO guidelines advise using injectable iron over oral iron  supplements because oral iron supplements are inadequate.2 Since IV iron cannot be  provided in general practice due to the requirement for monitoring, this presents a  challenge for most general practitioners. The KDIGO guideline also suggests using iron indices to help direct therapy, considering the risk of infection from excess iron and  inadequate ESA response.2 

Changes in symptoms, such as a decrease in fatigue in an individual patient, rather  than a hemoglobin concentration threshold, are a better measure of successful improvement.2 Importantly, the first section of the KDIGO guideline considers the  diagnosis and evaluation of anemia in later stages of CKD (Stage 3a and beyond),  where anemia is most common.2 The guidelines, while not graded, include protocol-type methods to the frequency of testing as well as a logical approach to diagnosis that is pertinent and suitable.2 It is expected that the updated guidelines will include newer evidence-based recommendations to improve aid to primary care clinicians and provide even better outcomes to patients.  


Recommendation for patients with CKD and anemia 1
Goal during supplemenation 1
KDIGO GuidelinesTrial of Iron if the TSAT is 30% and serum ferritin is <500 ng/mLRemain below TSAT of 30% and ferritin of 500 ng / mL
ERBP Guidelines Trial of Iron if the TSAT is 20% and serum ferritin is <100ng/mLRemain below TSAT of 30% and ferritin of 500 ng / mL
NICE GuidelinesRemain below ferritin of 800 ng/mL
Renal Association Guidelines (2017)Remain below ferritin of 800 ng/mL

TSAT, transferrin saturation; KDIGO, Kidney Disease: Improving Global Standards; ERBP, European Renal Best Practice; NICE, National Institute-for Health and Care Excellence


The KDIGO guidelines can help primary care clinicians manage patients with stage 3a and  3b CKD to investigate and rule out alternative reversible causes of anemia in the earlier  stages of CKD when CKD-associated anemia is most likely to develop.

In conclusion, the key KDIGO guideline recommendations for primary care clinicians and  other non-nephrologist clinicians are to:2 

• Consider CKD in any diagnostic workup of anemia.  

• Acknowledge that injectable, rather than oral iron is the  rst-line treatment for  CKD-associated anemia.  

• Consider ESA use only when the Hb level is about 10 g/dL — refer the patient to a  nephrologist at that time.  

• Be appropriately cautious with the use of transfusions (blood and platelets) if  transplantation potential exists. 


  1. KDIGO website. Anemia in CKD. Date accessed September 6, 2022.
  2. MacGinley RJ, International treatment guidelines for anaemia in chronic kidney disease – what has changed? Nephrologist and Convenor of Medicine, doing:10.5694/mja13.10538
  3. Moist LM. Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD – Canadian Society of Nephrology. AM J Kidney Dis. 2013;62(5):860-873
  4. Kliger AS. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD – Canadian Society of Nephrology. AM J Kidney Dis. 2013;62(5):849-859
  5. Batchelor EK, Kapitsinou P, Pergola PE, et al. Iron Deficiency 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. 
  6. After-Gvili A, Schechter A, Rozen-Zvi B. Iron Deficiency Anemia in Chronic Kidney Disease. Acta Haematol. 2019;142(1):44-50. doi: 10.1159/000496492. Epub 2019