# CKD Anemia: Iron First, Then an ESA Decision

KDIGO 2026 anemia guidance is final. Distinguish iron eligibility, iron withholding, and ESA targets; a normal Hb is not the treatment goal.

![Infographic: CKD Anemia: Iron First, Then an ESA Decision](https://urinenephrology.org/visual-reference/images/student-ckd-anemia.png?v=20261003c)

## Establish the cause

Start with CBC, reticulocytes, ferritin, and transferrin saturation (TSAT). Review bleeding, inflammation, B12/folate deficiency, and medications; CKD does not exclude another diagnosis. High ferritin can reflect inflammation. A falling Hb or iron deficiency warrants a cause-directed evaluation, not an automatic “renal anemia” label.

## Iron criteria: NO hemodialysis

For anemia in nondialysis CKD or peritoneal dialysis, KDIGO 2026 suggests iron when ferritin <100 ng/mL AND TSAT <40%, OR ferritin 100–<300 AND TSAT <25%. Choose oral or IV by severity, tolerance, response, access, and preference. Switch to IV after 1–3 months of inadequate oral response or poor tolerance.

## Iron criteria: HEMODIALYSIS

For anemia on hemodialysis, suggested initiation criteria are ferritin ≤500 ng/mL AND TSAT ≤30%; IV iron is preferred. These are treatment-entry criteria, not targets to chase. Ferritin 600 with low TSAT does not automatically mandate more iron: assess inflammation, losses, and treatment response.

## Recheck iron; know when to pause

During iron treatment, check Hb, ferritin, and TSAT every 3 months in nondialysis/PD and every 1–3 months in HD; test sooner with bleeding or changing treatment. Withhold routine iron if ferritin >700 or TSAT ≥40%. Temporarily suspend during systemic infection when appropriate.

## ESA: initiation differs by setting

Correct reversible causes first. In dialysis, consider ESA initiation at Hb ≤9–10 g/dL. Without dialysis, individualize—often 8.5–10—using symptoms, transfusion avoidance, stroke/thrombosis risk, and malignancy. Use the lowest effective dose with an adult Hb goal <11.5. Recheck Hb every 2–4 weeks after starting or changing dose.

## Worked example: sequence the decision

Synthetic example: nondialysis CKD, Hb 9.4, ferritin 60, TSAT 16%. Investigate iron loss and replace iron before escalating to ESA. If anemia persists, discuss ESA benefits and risks. Hb 9.4 alone mandates neither ESA nor transfusion; active bleeding, ischemic symptoms, or instability changes the urgency.

## Supporting evidence

- [KDIGO 2026 anemia guideline: recommendations2.1–2.4,3.2.1–3.3.1 and practice points2.2,2.5,2.7,2.8,3.4.3.2](https://kdigo.org/wp-content/uploads/2026/04/KDIGO-2026-Anemia-in-CKD-Guideline.pdf)
- [Supporting guideline or source](https://kdigo.org/guidelines/anemia-in-ckd/)
- [KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease.](https://pubmed.ncbi.nlm.nih.gov/41485812/)
- [Intravenous Iron in Patients Undergoing Maintenance Hemodialysis.](https://pubmed.ncbi.nlm.nih.gov/30365356/)
- [A Trial of Darbepoetin Alfa in Type 2 Diabetes and Chronic Kidney Disease.](https://pubmed.ncbi.nlm.nih.gov/19880844/)

## Source lessons

- [ckd anemia student handout](https://urinenephrology.org/student-resources/ckd/ckd-anemia-student-handout.html)
- [ckd complications student handout](https://urinenephrology.org/student-resources/ckd/ckd-complications-student-handout.html)
- [ckd comprehensive management pathways](https://urinenephrology.org/student-resources/ckd/ckd-comprehensive-management-pathways.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.