This protocol addresses anemia in the specific setting of chronic kidney disease G5 on hemodialysis (CKD G5HD) — a population with well-defined iron status thresholds that guide when to initiate therapy, which formulation to use, and how often to monitor.
In patients with anemia and chronic kidney disease G5 receiving hemodialysis, iron therapy is indicated when ferritin is ≤500 ng/ml and transferrin saturation (TSAT) is ≤30%. The protocol also specifies upper thresholds above which routine iron should be withheld.
The evidence-based approach centers on intravenous iron therapy — preferred over oral iron in this population — administered proactively at regular intervals to maintain stable iron status. Several intravenous formulations are available, each addressed in the full protocol.
The expected benefit is an increase in hemoglobin of approximately 0.5 g/dl, with improvement in ferritin and TSAT. Hemoglobin, ferritin, and TSAT should be monitored every 1–3 months in patients with CKD G5HD.
DOI: 10.1016/j.kint.2025.06.006
In people with anemia and CKD G5 receiving hemodialysis (CKD G5HD), we suggest initiating iron therapy if ferritin ≤500 ng/ml (≤500 μg/l) and TSAT ≤30% (2D).
In people with anemia and CKD G5HD who are initiating iron therapy, we suggest using intravenous (i.v.) iron rather than oral iron (2D).
In people with CKD G5HD in whom iron therapy is being initiated, administer i.v. iron using a proactive approach to maintain stable iron status.
In people with CKD treated with iron, it is reasonable to withhold routine iron if ferritin >700 ng/ml (>700 μg/l) or TSAT ≥40%.
Compared with placebo, iron supplementation agents seem to increase Hb values by an average of ~0.5 g/dl (~5 g/l) in people with CKD G5HD.
In people with CKD treated with iron, it is reasonable to test hemoglobin (Hb), ferritin, and TSAT every 3 months for those with CKD not receiving dialysis or CKD G5PD and every 1–3 months for those with CKD G5HD.
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