Treatment of Anemia in Chronic Kidney Disease Not Receiving Dialysis
Clinical Scenario
This protocol applies to patients with anemia in the setting of chronic kidney disease (CKD) who are not receiving dialysis, including kidney transplant recipients. In this population, anemia and CKD co-exist and require a structured, evidence-based approach to iron-status evaluation before broader treatment decisions are made.
Treatment Approach — Partial Overview
Management begins with assessment of iron-status markers — specifically ferritin and transferrin saturation (TSAT) — against defined thresholds that determine whether iron therapy should be initiated, withheld, or reconsidered. When initiation is indicated, therapy may be delivered orally or intravenously, with the route selected based on the degree of anemia, relative efficacy, tolerability, availability, and cost. A switch between routes may apply if the initial approach proves insufficient.
The complete agent selection, sequencing, switching criteria, and all numeric thresholds are in the full structured protocol.
Full regimen available via protocol access
Treatment Goals
The primary aim is an increase in hemoglobin concentration, alongside improvement in ferritin and TSAT. Hemoglobin, ferritin, and TSAT are monitored at regular intervals throughout treatment to guide ongoing decisions.
References
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 not receiving hemodialysis (HD) in whom iron is initiated, we suggest using either oral iron or i.v. iron based on the person’s values and preferences, the degree of anemia and iron deficiency, and the relative efficacy, tolerability, availability, and cost of each (2D).
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).
Iron probably increases the Hb concentration on average by ~0.65–1.0 g/dl (~6.5–10 g/l) compared with no iron.
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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