Evaluation and Management of Anemia in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2026 Clinical Practice Guideline.

Abstract

The Kidney Disease: Improving Global Outcomes (KDIGO) 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD) provides an update of the 2012 version. Its scope includes anemia diagnosis and use of iron therapy, erythropoiesis-stimulating agents (ESAs), hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs), and red blood cell (RBC) transfusions to treat anemia in CKD. An international work group of patient partners, health care professionals, researchers, and clinicians defined the guideline scope. An independent evidence review team conducted systematic reviews through October 2024 and graded the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. The final guideline incorporated feedback from a public review involving registered stakeholders in late 2024. This synopsis focuses on the 8 graded recommendations. Key points include the use of transferrin saturation and ferritin thresholds to guide iron therapy, with intravenous iron preferred over oral iron in people receiving hemodialysis; addressing correctable causes of anemia before use of an ESA or a HIF-PHI; using an ESA rather than a HIF-PHI as first-line treatment; individualized hemoglobin (Hb) thresholds for ESA initiation based on patient characteristics, symptoms, and values; and an upper Hb target of below 11.5 g/dL (<115 g/L) during ESA maintenance therapy. The guideline also includes 49 practice points representing expert consensus where robust evidence was limited or systematic review could not be conducted.