KDIGO 2026: anaemia in chronic kidney disease

Kidney Disease: Improving Global Outcomes has replaced its 2012 guideline on anaemia in chronic kidney disease. A synopsis of the eight graded recommendations appeared in Annals of Internal Medicine on 15 September 2026. The evidence review ran to October 2024 and used GRADE.

The key points: use transferrin saturation and ferritin thresholds to guide iron therapy; prefer intravenous over oral iron in people on haemodialysis; correct reversible causes of anaemia before starting an erythropoiesis-stimulating agent (ESA) or a HIF prolyl hydroxylase inhibitor (HIF-PHI); use an ESA rather than a HIF-PHI first line; set the haemoglobin threshold for starting an ESA individually; and keep haemoglobin below 11.5 g/dL during ESA maintenance.

For a non-nephrologist the practical parts are the first and third: check iron studies in anaemic patients with CKD, and look for bleeding, B12 or folate deficiency and other causes before anyone reaches for an injection. The guideline also carries 49 practice points based on expert consensus where evidence was thin.

• Check ferritin and transferrin saturation in anaemic patients with CKD
• Look for bleeding, B12 or folate deficiency and hypothyroidism before ESA therapy
• Prefer intravenous iron for patients on haemodialysis
• Use an ESA before a HIF-PHI as first-line treatment
• Avoid pushing haemoglobin above 11.5 g/dL on an ESA

Why it matters

It sets a single international standard for CKD anaemia after 14 years, including where the newer HIF-PHI tablets fit.

Don't overread it

Most of the guideline's content is practice points from expert consensus; only eight recommendations are graded.

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