This protocol applies to patients with anemia in the setting of chronic kidney disease stage G5 who are receiving peritoneal dialysis, where an initial course of iron therapy has not achieved the expected hemoglobin response.
Anemia in chronic kidney disease G5 (CKD G5PD) in patients on peritoneal dialysis is a specific sub-population requiring stage-specific, structured management. Iron status thresholds — ferritin and transferrin saturation — guide the initial intervention and inform when escalation is warranted.
Iron therapy is the first-line intervention in this population, initiated based on ferritin and TSAT thresholds. Escalation to the next treatment line is indicated when iron therapy has not achieved the expected hemoglobin increase of approximately 0.65–1.0 g/dl, or when ferritin and TSAT targets remain unmet after an adequate course.
Following insufficient hemoglobin response to iron therapy, an erythropoiesis-stimulating agent (ESA) — preferred over an alternative drug class — becomes the recommended first-line treatment of anemia in this population.
The aim is to increase hemoglobin by approximately 1.0 g/dl per month while maintaining it below 11.5 g/dl, with hemoglobin monitored every 2–4 weeks following initiation or dose change.
DOI: 10.1016/j.kint.2025.06.006
In people with anemia and CKD not receiving dialysis or CKD G5 receiving peritoneal dialysis (CKD G5PD), we suggest initiating iron if (2D): Ferritin <100 ng/ml (<100 μg/l) and TSAT <40% or Ferritin ≥100 ng/ml (≥100 μg/l) and <300 ng/ml (<300 μg/l), and TSAT <25%.
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 and children with anemia and CKD not receiving dialysis, those with CKD G5PD, or kidney transplant recipients receiving ESA therapy, administer ESA via the subcutaneous route.
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.
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