Mario Jimenez: KDIGO 2026 – A More Proactive Approach to IV Iron in Hemodialysis
Mario Jimenez, Master in transplantation at University of Barcelona, Professor of Nephrology at UDLAP/BUAP Hospital, shared a post on X about a recent article by Lucia Del Vecchio et al., published in Nephrology Dialysis Transplantation, adding:
“Anemia in Hemodialysis: KDIGO 2026 Shifts Focus Toward More Proactive Use of IV Iron The KDIGO 2026 update for anemia in CKD, highlighted this month by NDT, incorporates major practical changes after more than a decade without a significant revision.
In hemodialysis patients, KDIGO proposes considering IV iron when TSAT is equal to or less than 30% and ferritin s equal to or less than 500 ng/mL, and favors a proactive strategy, not solely reactive.
It also suggests routinely suspending iron when: ferritin is equal to or more than 700 ng/mL or TSAT is equal to or more than 40%.
The rationale continues to rely on the PIVOTAL trial experience: administering iron proactively can reduce ESA requirements and transfusions without waiting for frank absolute deficiency to appear.
Clinical takeaway: in hemodialysis, a ‘normal or high’ ferritin does not rule out iron-restricted erythropoiesis.
TSAT and ferritin must be interpreted together.
Practical application for the nephrologist: before increasing ESA in the face of persistently low Hb, review available iron, inflammation, blood losses, infection, hyperparathyroidism, nutrition, and dialysis adequacy.
KDIGO further insists on avoiding repeated ESA escalations when there is hyporesponsiveness and seeking reversible causes first.
Another important point: despite the development of HIF-PHIs, ESAs continue to be the first-line treatment in many scenarios, while uncertainties persist regarding the long-term cardiovascular safety of HIF-PHIs.
Modern renal anemia should no longer be treated by asking solely: ‘How much erythropoietin does this patient need?’ but rather: ‘Why is this patient not producing hemoglobin efficiently?'”
Title: KDIGO 2026 Clinical Practice Guideline for Anemia in Chronic Kidney Disease (CKD): a commentary from the European Renal Best Practice (ERBP)
Authors: Lucia Del Vecchio, Aleix Cases, Michele F Eisenga, Jolanta Małyszko, Jonathan Barratt, Davide Bolignano
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