The KDIGO 2026 guideline on anaemia in chronic kidney disease, summarised in Annals of Internal Medicine (15 September 2026), replaces the 2012 version. It carries eight graded recommendations, built on GRADE-assessed systematic reviews to October 2024, and 49 expert practice points.
The graded recommendations: use transferrin saturation and ferritin thresholds to guide iron; prefer intravenous over oral iron in people on haemodialysis; correct reversible causes of anaemia before starting an erythropoiesis-stimulating agent (ESA) or a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI); use an ESA rather than a HIF-PHI first line; individualise the haemoglobin at which an ESA is started; and keep maintenance haemoglobin below 11.5 g/dL.
Most of the guideline is practice points — expert consensus where trials are thin — so its firmest parts are the iron and ESA-first recommendations and the upper haemoglobin limit.
For the physician managing CKD anaemia on the ward or in clinic, the order is unchanged but now explicit: iron studies, correct iron and other causes, then ESA, and do not chase a normal haemoglobin.
- Check transferrin saturation and ferritin, B12, folate and a blood film before attributing anaemia to CKD
- Replace iron before considering an ESA; use intravenous iron in patients on haemodialysis
- Choose an ESA over a HIF-PH inhibitor such as daprodustat or roxadustat as first line
- Start an ESA at a haemoglobin individualised to symptoms and patient values, not a fixed number
- Keep maintenance haemoglobin below 11.5 g/dL on an ESA
Why it matters
It sets ESAs ahead of the oral HIF-PH inhibitors that have been marketed as a simpler alternative.
Don't overread it
Most of the guideline is expert-consensus practice points; only eight recommendations are graded.
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