Treatment of Anemia in Chronic Kidney Disease G5 on Hemodialysis When Intravenous Iron Has Not Met Targets
This protocol is for patients with anemia and chronic kidney disease stage G5 (CKD G5) receiving hemodialysis (CKD G5HD) who have undergone intravenous iron therapy but have not achieved the expected hemoglobin response or iron store targets.
Clinical Scenario
Anemia in patients with CKD G5 receiving hemodialysis — a common and clinically significant comorbidity in end-stage kidney disease on renal replacement therapy.
Prior Treatment — Intravenous Iron: Goals Not Reached
The preceding treatment step used intravenous iron, targeting an average hemoglobin increase of approximately 0.5 g/dl and improvements in ferritin and transferrin saturation (TSAT). When these goals are not achieved, the protocol advances to the next treatment line.
Next-Step Approach
The protocol introduces an erythropoiesis-stimulating agent (ESA) as the preferred next-line approach — prioritised over an alternative drug class. The specific initiation criteria, monitoring requirements, and dosing algorithm are set out in the full protocol.
Clinical Goals
Target: an increase in hemoglobin of 1.0 g/dl per month, with hemoglobin maintained below 11.5 g/dl. Hemoglobin is monitored every 2–4 weeks after initiation or dose change.
References
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 in whom correctable causes of anemia have been addressed, we suggest using an ESA rather than a HIF-PHI as first-line treatment of anemia (2D).
- In people with anemia and CKD G5D receiving HD or peritoneal dialysis, we suggest initiation of ESA therapy when the Hb concentration is ≤9.0–10.0 g/dl (≤90–100 g/l) (2D).
- In adults with anemia and CKD treated with ESAs, we recommend targeting the Hb level to below 11.5 g/dl (115 g/l) (1D).
- 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.