This protocol applies to children under 18 years of age with anemia in the context of chronic kidney disease (CKD). Management in this population must account for hemoglobin correction alongside growth and development considerations, and the potential effect on eligibility for future kidney transplantation.
First-line management in children with CKD-related anemia involves iron therapy (oral or intravenous iron), aimed at improving hemoglobin levels and reducing the erythropoiesis-stimulating agent dose required to maintain the target hemoglobin. When iron therapy has not achieved these hemoglobin goals, escalation to the next treatment step is warranted.
The next step centres on erythropoiesis-stimulating agent (ESA) therapy, initiated at a hemoglobin concentration determined individually — taking into account the child's symptoms, growth trajectory, and allosensitization risk ahead of potential transplantation. The specific agent selection, route, and individualized dosing strategy are set out in the full protocol.
Initial ESA therapy targets a hemoglobin rise of 1.0 g/dl per month. Hemoglobin is monitored every 2–4 weeks following treatment initiation or any dose change, with the maintenance target set individually for each child.
DOI: 10.1016/j.kint.2025.06.006
ESAs are effective in children, while HIF-PHIs have not been studied in children.
There are insufficient data for efficacy and safety regarding the use of HIF-PHIs for the treatment of children with anemia and CKD G5D or CKD not receiving dialysis.
In people with CKD not receiving dialysis, including kidney transplant recipients and children, the selection of Hb concentration at which ESA therapy is initiated should consider the presence of symptoms attributable to anemia, the potential benefits of higher Hb concentration, and the potential harms of RBC transfusions or ESA therapy (2D).
We advise considering these data as well as patient symptoms, QoL, growth and development, and the need to limit allosensitization from RBC transfusion when deciding when to initiate ESA therapy in children.
In general, weight-based dosing is used for children.
Initial therapy with an ESA aims to increase the Hb concentration by 1.0 g/dl (10 g/l) per month, which is consistent with the findings in clinical trials that used an ESA to treat anemia in people with CKD G5D and CKD not receiving dialysis.
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