KDIGO Releases New Guideline for Anemia in Chronic Kidney Disease

The Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group has released the 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD), updating the prior 2012 guideline with data on iron management, red blood cell (RBC) transfusions, and other recommendations and practice points.1

Anemia is a well-known comorbidity of CKD, increasing in severity as CKD advances. It impacts >50% of people with CKD. Anemia’s pathophysiology in CKD is multifactorial, impacted by relative erythropoietin deficiency and bone marrow erythropoietin resistance, iron deficiencies, blood loss, systemic inflammation, and shortened RBC survival. Additionally, anemia has been associated with a series of adverse outcomes, including increased mortality, cardiovascular disease, heart failure, cognitive impairment, and others.2

“This guideline represents a major step forward in how we approach anemia in CKD,” Jodie Babitt, MD, co-chair of the guidelines, professor of medicine at Harvard Medical School, and attending physician on inpatient nephrology, ICU, and dialysis at Massachusetts General Hospital, said in a statement. “It emphasizes a systematic evaluation of anemia and iron deficiency, clearer guidance on when and how to use oral and intravenous iron, and a more nuanced, individualized approach to anemia treatment that weighs symptoms, risks, and patient preferences. Importantly, the guideline integrates new evidence on emerging therapies while reinforcing the need to avoid overtreatment and to prioritize safety and shared decision-making.”3

After the 2012 guidelines were published, KDIGO held 2 Controversies Conferences on anemia management in CKD populations – the first was in December 2019, and the second in December 2021. The former covered optimal anemia management, pathogenesis, and diagnosis of iron deficiency and anemia in CKD, and the use of iron agents in CKD anemia management. The latter focused on novel anemia therapies, such as hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs). During this second conference, participants agreed on the value and timeliness of updated guidelines.2

The 2026 guideline is made up of 4 main chapters. The first covers the diagnosis and evaluation of anemia and iron deficiency in patients with CKD, including their prevalence, pathophysiology, and associated outcomes. The second discusses the use of iron to treat deficiency in patients with anemia and CKD, providing guidance on prioritizing intravenous rather than oral iron.1

The third chapter involves the use of erythropoiesis-stimulating agents (ESAs) and HIF-PHIs to raise hemoglobin, highlighting the importance of shared decision-making and addressing all other potential causes before beginning treatment. The fourth and final chapter details the situations in which clinicians should use RBC transfusions, emphasizing the potential drawbacks to this approach in certain patients and encouraging the examination of symptoms and signs rather than hemoglobin threshold when assigning RBC transfusions.1

Ultimately, the guideline is explicitly intended to inform, but not dictate, clinical practice. The authors encourage the liberal use of clinical judgement and the accommodation of patient circumstances and preferences. Patient-centered care is emphasized throughout, aiming to ensure global relevance irrespective of the clinical setting.1

“Rather than promoting a single approach, the guideline supports individualized decision-making that considers symptoms, comorbidities, treatment risks, and patient preferences,” Marcello Tonelli, MD, MSc, co-chair of the guideline, associate vice president of health research at the University of Calgary, and senior associate dean of clinical research at the Cumming School of Medicine, said in a statement. “By incorporating population-based treatment algorithms and practice points alongside graded recommendations, we aimed to support consistent, evidence-informed anemia care across diverse healthcare systems, resource settings, and patient populations worldwide.”3

References

1. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD). Kidney Int. 2026;109(1S):S1–S99. https://doi.org/10.1016/j.kint.2025.06.006

2. Babitt J, Berns J, Bozkurt B, et al. Executive Summary of the KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease (CKD). Kidney International. 2026;109(1):44-56. https://doi.org/10.1016/j.kint.2025.06.005

3. Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO Announces Publication of Anemia in CKD Guideline. January 2, 2026. Accessed January 5, 2026. https://kdigo.org/kdigo-announces-publication-of-anemia-in-ckd-guideline/