This protocol applies to patients with anemia in the context of chronic kidney disease (CKD) who are not currently receiving dialysis — including kidney transplant recipients — in whom iron therapy has not achieved an adequate hemoglobin response.
The patient has confirmed anemia alongside chronic kidney disease and is not receiving dialysis. An initial course of iron therapy has been completed or trialled, but hemoglobin and iron store targets have not been reached. This pattern signals the need for the next treatment step.
Prior therapy: Iron therapy — oral or intravenous, selected based on iron store markers.
Goals that were not met:
When these markers — assessed at 3-month intervals — are not reached, the protocol escalates to the current line.
Once correctable causes of anemia have been addressed and iron therapy proves insufficient, the protocol calls for an erythropoiesis-stimulating agent (ESA) as the first-line next step — recommended over an alternative agent class — initiated at an individualized hemoglobin concentration and targeting a defined upper hemoglobin ceiling.
Full agent selection, administration details, initiation criteria, and monitoring schedule are contained in the complete protocol ↓The goal is a controlled, steady rise in hemoglobin concentration each month, maintained below a specified upper limit. Hemoglobin is monitored at defined intervals following initiation and any dose change. Specific thresholds and intervals are set out in the full protocol.
DOI: 10.1016/j.kint.2025.06.006
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).
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 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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