Education Use Only
For educational use only — The physician’s written order and the unit protocol always govern
Medical Associates  ·  Department of Nephrology ← Nursing cards  ·  Maintenance Hemodialysis  ·  urinenephrology.org
Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N10 — Anemia Protocol: ESA and Iron Hold/Report Rules

Check before every dose, hold at the thresholds, report the patterns.
Andrew Bland, MD, FACP, FAAP Reviewed September 2026 · v1.0 draft Prints on one sheet, front and back
N10 — Anemia Protocol: ESA and Iron Hold/Report Rules FRONT
Front · at the chair

When: every ESA or IV iron dose and monthly anemia review. Your unit protocol sets the dosing schedule and governs where its numbers differ.

Do this

  1. Before every ESA dose: check the latest hemoglobin (Hb) against your protocol’s band, and whether a 2-week recheck is due after a dose change [2,7].
  2. Check pre-treatment BP before giving an ESA; uncontrolled hypertension is a contraindication [2].
  3. Before every iron dose, check for infection: fever, chills on connection, a positive blood culture, a red or draining exit site, current antibiotics [7].
  4. Give IV iron on your unit protocol’s schedule, early in the treatment. Iron sucrose: slow IV over 2–5 minutes or an infusion of at least 15 minutes [6].
  5. Observe at least 30 minutes after IV iron with anaphylaxis medicines at the chair. Ferumoxytol is infused over at least 15 minutes — never pushed [6,8].
  6. Ask every treatment: black stools, prolonged needle-site bleeding, chest pain, dyspnea, new neurologic symptoms, a clotted access, a recent admission.

Call the nephrologist when

  • Hb rises more than 1 g/dL in 2 weeks (dose reduction due), or reaches your protocol’s hold threshold (11 g/dL on label-based protocols; KDIGO 2026 targets below 11.5 g/dL) [2,7].
  • Hb drops 1 g/dL or more unexpectedly, falls below 9 g/dL, or causes symptoms.
  • The patient was hospitalized for stroke, heart attack, blood clot, or access thrombosis — ESA held pending review [7].
  • BP is persistently uncontrolled, or there is a new seizure [2].
  • Hold iron: active infection; ferritin above 700 ng/mL or TSAT 40% or higher; TSAT below 20% with ferritin above 700 unless a physician’s high-ferritin trial order is active [7].
  • A 1-gram iron course is ordered for a catheter patient or anyone with an infection in the past month — ask whether it should be split [4].
  • ESA doubled or raised twice without response; any iron reaction; MRI planned after recent ferumoxytol [8].

Don’t

  • Don’t give an ESA and a HIF-PH inhibitor together [7].
  • Don’t raise an ESA dose more often than every 4 weeks [2,7].
  • Don’t use 1-gram courses as maintenance iron [4].
  • Don’t transfuse a transplant candidate electively without the nephrologist [7].
  • Don’t premedicate or test-dose modern non-dextran IV iron routinely unless your protocol says to [7].
N10 — Anemia Protocol: ESA and Iron Hold/Report Rules BACK
Back · why, and the evidence

Why

  1. Normal is not the goal. In hemodialysis patients with heart disease, targeting a hematocrit of 42% instead of 30% increased death or heart attack (32.7% vs 26.7%) [1].
  2. Fast rises are the dangerous ones. The epoetin label requires a dose cut of 25% or more when Hb rises more than 1 g/dL in 2 weeks, and warns of death, stroke, and access clotting [2].
  3. Steady iron helps. Proactive IV iron lowered death, heart attack, stroke, or heart-failure hospitalization (29.3% vs 32.3%) and used 19% less ESA [3].
  4. Too much at once costs infections. Large repletion courses were linked to 25 more infection hospitalizations per 1,000 patient-years than steady maintenance — 73 more in catheter patients [4].
  5. Iron reactions are rare but real. Life-threatening reactions to iron sucrose occur at about 0.6 per million doses [5]; the label asks for at least 30 minutes of observation [6].

Go deeper

References

  1. Besarab A, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med. 1998;339:584-590. PubMed 9718377
  2. Amgen Inc. EPOGEN (epoetin alfa) injection, prescribing information. Revised April 2024. accessdata.fda.gov
  3. Macdougall IC, et al. Intravenous iron in patients undergoing maintenance hemodialysis (PIVOTAL). N Engl J Med. 2019;380:447-458. PubMed 30365356
  4. Brookhart MA, et al. Infection risk with bolus versus maintenance iron supplementation in hemodialysis patients. J Am Soc Nephrol. 2013;24:1151-1158. PubMed 23787911
  5. Chertow GM, et al. Update on adverse drug events associated with parenteral iron. Nephrol Dial Transplant. 2006;21:378-382. PubMed 16286429
  6. American Regent, Inc. VENOFER (iron sucrose) injection, prescribing information (2020). accessdata.fda.gov
  7. KDIGO Anemia Work Group. KDIGO 2026 clinical practice guideline for the management of anemia in CKD. Kidney Int. 2026;109(1S):S1-S99. PubMed 41485812
  8. AMAG Pharmaceuticals. FERAHEME (ferumoxytol) injection, prescribing information with boxed warning (2015). accessdata.fda.gov

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.