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Basyouni Omran: KDIGO 2025/2026 Bedside Guide – Iron Correction in CKD

Basyouni Omran/LinkedIn

Aug 5, 2026, 23:28

Basyouni Omran: KDIGO 2025/2026 Bedside Guide – Iron Correction in CKD

Basyouni Omran, ICU registrar at Andalusia Health KSA, shared a post on LinkedIn:

“KDIGO 2025/2026 Bedside Guide: Iron Correction in Chronic Kidney Disease (CKD)

Iron deficiency remains one of the most common reversible causes of anemia in patients with CKD.

Appropriate assessment of Ferritin and Transferrin Saturation (TSAT) allows timely iron replacement while minimizing the risk of iron overload.

1.When to start Iron Therapy (Initiation Thresholds)

Hemodialysis (CKD G5HD)

Ferritin till 500 ng/mL AND
TSAT till 30%

Non-Dialysis CKD (ND-CKD)

Ferritin less than 100 ng/mL AND
TSAT less than 40%

Peritoneal Dialysis (PD)

Ferritin less than 300 ng/mL AND
TSAT less than 25%

Important Note:

For ND-CKD and PD patients, Ferritin less than 100 ng/mL alone is sufficient to consider iron therapy regardless of TSAT.

2. Treatment Algorithm

Start – Assess Iron Status – Initiate Iron Therapy – Monitor Response

3. When to STOP / Withhold Iron

To reduce the risk of iron overload, routine iron therapy should be withheld when:

Ferritin >700 ng/mL

or

TSAT ≥40%

4. Updated Pathophysiology

Systemic Iron Deficiency

Low Ferritin and Low TSAT

Represents depleted iron stores.

Iron-Restricted Erythropoiesis (Functional Iron Deficiency)

Normal/High Ferritin and Low TSAT

Iron stores are present but unavailable for erythropoiesis due to inflammation and hepcidin-mediated sequestration.

Monitoring Frequency

CKD Stage 3

Hb, Ferritin & TSAT Annually

CKD Stage 4

Every 6 months

CKD Stage 5 / Dialysis

Every 3 months

Increase monitoring during:

ESA initiation or dose adjustment
HIF-PHI therapy
Active blood loss
Clinical instability

Clinical Pearls

Active Infection

Pause IV iron during active systemic infections.

Preferred Route

Hemodialysis – IV Iron is preferred
ND-CKD and PD – Oral or IV iron depending on severity, patient preference, and tolerance.

Refractory Anemia

In selected patients with persistent anemia despite ESA therapy, a carefully monitored IV iron trial may still be considered even if Ferritin is >700 ng/mL when TSAT remains markedly low.

Take-Home Message

Always interpret Ferritin and TSAT together rather than relying on a single parameter.
Avoid unnecessary iron administration once overload thresholds are reached.
Individualize therapy according to CKD stage, dialysis modality, inflammation, ESA use, and clinical status.

Basyouni Omran