The KDIGO 2026 guideline updates the 2012 advice on anaemia in chronic kidney disease, and arrives as oral hypoxia-inducible-factor prolyl-hydroxylase inhibitors (HIF-PHIs) have become an alternative to injectable erythropoiesis-stimulating agents (ESAs). Across eight graded recommendations, it sets clearer defaults.
Several are practical. Transferrin saturation and ferritin thresholds guide iron therapy, with intravenous iron preferred over oral in people on haemodialysis. Correctable causes of anaemia should be addressed before starting an ESA or a HIF-PHI. When an agent is needed, an ESA is recommended as first-line over a HIF-PHI. Haemoglobin thresholds for starting an ESA should be individualised, and the maintenance target kept below 11.5 g/dL.
The headline for a general physician is that the newer oral agents do not displace ESAs as first choice, and that the ceiling on haemoglobin remains deliberately conservative to avoid the harms seen with fuller correction.
- Updates the 2012 KDIGO anaemia guidance across eight graded recommendations.
- Erythropoiesis-stimulating agents are recommended first-line over oral HIF-PHIs.
- Intravenous iron is preferred over oral iron in haemodialysis patients.
- Correct other causes of anaemia before starting an ESA or HIF-PHI.
- Keep the maintenance haemoglobin target below 11.5 g/dL.
Why it matters
It settles where the newer oral agents sit: as an alternative, not a replacement for ESAs as first choice.
Don't overread it
Recommending ESAs first-line reflects the overall evidence balance, not a safety verdict against HIF-PHIs, which remain an option.
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