The Kidney Disease: Improving Global Outcomes (KDIGO) 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD) provides a comprehensive update to the 2012 guideline, incorporating over a decade of new evidence on anemia pathophysiology, diagnosis, and treatment. Anemia remains a prevalent complication in CKD, associated with reduced quality of life, increased cardiovascular risk, higher hospitalization rates, and greater need for transfusions. This guideline targets healthcare providers, patients, and stakeholders involved in caring for adults and children with CKD-associated anemia, including those not on dialysis, on hemodialysis or peritoneal dialysis, or post-kidney transplantation.
Key updates include revised nomenclature: “absolute iron deficiency” is replaced by “systemic iron deficiency,” and “functional iron deficiency” by “iron-restricted erythropoiesis,” to more precisely reflect underlying mechanisms.
The guideline is structured around four main chapters: (1) diagnosis and evaluation of anemia, with recommended testing frequencies, hemoglobin thresholds (<13 g/dL in males, <12 g/dL in females), iron status markers (ferritin, transferrin saturation), and flowcharts for evaluation across CKD stages; (2) iron therapy initiation and routes (preferring intravenous in dialysis settings), with specific thresholds and proactive strategies to maintain iron stores while avoiding overload; (3) use of erythropoiesis-stimulating agents (ESAs) as first-line, HIF-PHIs as alternatives (with cautions for risks like thrombosis or malignancy), individualized hemoglobin targets (generally below 11.5 g/dL to minimize cardiovascular and stroke risks), and management of hyporesponsiveness; and (4) judicious red blood cell transfusions, emphasizing risks such as allosensitization in transplant candidates and strategies to minimize use.
Recommendations are graded using the GRADE framework based on systematic reviews of randomized controlled trials through October 2024, supplemented by practice points, infographics, and population-specific algorithms for practical implementation. The guideline prioritizes patient-centered care, shared decision-making considering symptoms, risks, and preferences, and addresses limitations in current evidence while proposing research priorities, such as outcomes of iron therapy without anemia and novel agents in special populations. Overall, it aims to optimize anemia management globally, balancing benefits like improved hemoglobin and symptoms against potential harms.
Link: https://kdigo.org/wp-content/uploads/2026/01/KDIGO-2026-Anemia-in-CKD-Guideline.pdf
