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

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 \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2),[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
2.  **Check pre-treatment BP** before giving an ESA; uncontrolled hypertension is a contraindication \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2)\].
3.  **Before every iron dose, check for infection:** fever, chills on connection, a positive blood culture, a red or draining exit site, current antibiotics \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-6)\].
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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-6),[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-8)\].
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) \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2),[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- 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 \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- BP is persistently uncontrolled, or there is a new seizure \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2)\].
- **Iron hold/review:** consider temporary suspension during systemic infection and obtain prescriber direction under the authorized protocol; withhold routine iron for 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 \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- 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 \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-4)\].
- ESA doubled or raised twice without response; any iron reaction; MRI planned after recent ferumoxytol \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-8)\].

### Don’t

- Don’t give an ESA and a HIF-PH inhibitor together \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- Don’t raise an ESA dose more often than every 4 weeks \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2),[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- Don’t use 1-gram courses as maintenance iron \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-4)\].
- Don’t transfuse a transplant candidate electively without the nephrologist \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].
- Don’t premedicate or test-dose modern non-dextran IV iron routinely unless your protocol says to \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-7)\].

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%) \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-1)\].
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 \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-2)\].
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 \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-3)\].
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 \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-4)\].
5.  **Iron reactions are rare but real.** Life-threatening reactions to iron sucrose occur at about 0.6 per million doses \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-5)\]; the label asks for at least 30 minutes of observation \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html#n10-ref-6)\].

### Go deeper

- Mastery page: [Anemia: Targets, ESAs, and Hyporesponsiveness](https://urinenephrology.org/mastery/maintenance-hd/anemia-targets-esa-hyporesponsiveness.html)
- Mastery page: [Anemia: Iron, HIF-PH Inhibitors, and Transfusion](https://urinenephrology.org/mastery/maintenance-hd/iron-hif-transfusion-hd.html)
- [All dialysis nursing reference cards](https://urinenephrology.org/mastery/maintenance-hd/nursing/index.html)

### 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](https://pubmed.ncbi.nlm.nih.gov/9718377/)
2.  Amgen Inc. EPOGEN (epoetin alfa) injection, prescribing information. Revised April 2024. [accessdata.fda.gov](https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/103234s5378lbl.pdf)
3.  Macdougall IC, et al. Intravenous iron in patients undergoing maintenance hemodialysis (PIVOTAL). *N Engl J Med.* 2019;380:447-458. [PubMed 30365356](https://pubmed.ncbi.nlm.nih.gov/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](https://pubmed.ncbi.nlm.nih.gov/23787911/)
5.  Chertow GM, et al. Update on adverse drug events associated with parenteral iron. *Nephrol Dial Transplant.* 2006;21:378-382. [PubMed 16286429](https://pubmed.ncbi.nlm.nih.gov/16286429/)
6.  American Regent, Inc. VENOFER (iron sucrose) injection, prescribing information (2020). [accessdata.fda.gov](https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021135s036lbl.pdf)
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](https://pubmed.ncbi.nlm.nih.gov/41485812/)
8.  AMAG Pharmaceuticals. FERAHEME (ferumoxytol) injection, prescribing information with boxed warning (2015). [accessdata.fda.gov](https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/022180s011s013lbl.pdf)

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.


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[Website version](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html) · Markdown synchronized October 3, 2026.