Anaemia is common in chronic kidney disease (CKD), encompassing non-dialysis dependent CKD (NDD-CKD) and dialysis dependent CKD (DD-CKD); people on peritoneal dialysis (PD) and haemodialysis (HD); and kidney transplant recipients (KTR). Iron deficiency and erythropoietin deficiency (a consequence of impaired oxygen sensing by the failing kidneys) are perhaps the most common causes of anaemia in people with CKD, especially those requiring kidney replacement therapy (KRT/dialysis). The Renal National Service Framework and National Institute for Health and Clinical Excellence in the UK, and Kidney Disease Improving Global Outcomes (KDIGO), all advocate treatment of anaemia in people with CKD. Blood transfusions are infrequently required, and newer therapies such as Hypoxia-Inducible Factor (HIF-PHI) stabilisers are now in current use. Anaemia is a major clinical problem in people suffering from CKD. This guideline adds to the previous 2017 and updated 2020 anaemia guidelines. 

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This 2024 clinical practice guideline provides updated recommendations on the management of Anaemia of Chronic Kidney Disease (ACKD), including people receiving kidney replacement therapy, and serves to supersede all previously published UK guidelines. Recommendations have been graded using the modified GRADE system to indicate both the strength of each recommendation (strong or weak) and level of evidence for the recommendation (A-D) (1, 2). The UK Kidney Association (UKKA) endorses the NICE Guideline for anaemia management in Chronic Kidney Disease (CKD) 2021 (3).

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Assessment for Anaemia of CKD 

Treatment of Anaemia of CKD with Iron

Treatment of Anaemia with Erythropoiesis Stimulating Agents

Treatment of Anaemia with HIF-PHI Agents

Treatment of Anaemia of CKD with Blood Transfusions

Management of Peri-Transplant and Post-Transplant Anaemia

Special Populations

1. Proportion of people starting an ESA without prior measurement of serum ferritin and TSAT (or % HRC or CHr or Ret-He).
2. Proportion of people with non-dialysis dependent CKD with an eGFR < 30 ml/min/1.73m2 (CKD-EPI) with an annual haemoglobin level.
3. Proportion of people with non-dialysis dependent CKD stage 4-5 with Hb 100-120 g/L.
4. Proportion of people with dialysis dependent CKD on Peritoneal Dialysis receiving iron therapy; type: oral vs. parenteral.

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We recommend the following further research including, wherever possible, randomised trials:

1. RCT to evaluate the impact of IV versus oral iron in people on peritoneal dialysis.
2. RCT of IV iron on hard clinical outcomes in people with non-dialysis dependent CKD but without anaemia.
3. RCT of oral iron dosing in people with non-dialysis dependent CKD.
4. Determination of optimal iron dosing and regimes for HIF-PHI based therapy.
5. Use of HIF-PHI in certain sub-groups such as DM, ADPKD, diabetic retinopathy, ESA hyporesponsiveness and allergy to IV iron.

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Assessment for Anaemia of CKD (Guidelines 1.1 – 1.5)

Screening for Anaemia

Haemoglobin Level

Kidney Function

Erythropoietin Measurement

Baseline Investigations

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Several new areas of drug development are ongoing including inhibitors of hepcidin production or action, anti-interleukin-6 specific antibodies (Ziltivekimab), anti-inflammatory biologicals, and activin receptor ligand traps (1).

A phase 1/2, placebo-controlled trial examined the effects of intravenous ziltivekimab every 2 weeks for 12 weeks vs placebo, in 61 people on haemodialy sis with a single nucleotide polymorphism of the TMPRSS6 gene (putatively increases susceptibility to IL-6–mediated inflammatory effects). Ziltivekimab led to a significantly greater reduction of high-sensitivity C-reactive protein and ESA usage and ESA resistance index. There was also an increased serum iron, total iron binding capacity, transferrin saturation, and serum albumin (2). Future trials may define its benefit.

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Anaemia is a commonly diagnosed complication among people suffering with chronic kidney disease. If left untreated, it may affect quality of life. There are several causes for anaemia in this population. As the kidney function deteriorates, together with medications and dietary restrictions, people with chronic kidney disease may develop iron deficiency, resulting in reduction of iron supply to the bone marrow (which is the body organ responsible for the production of different blood elements). 

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Patient Information Sheet:

One of the kidneys’ main jobs is to help make red blood cells. The kidneys make a hormone called erythropoietin that is a signal for the body to make red blood cells.

If your kidneys don’t work as well as they should, they make less erythropoietin, so fewer red blood cells are made. Iron levels in the body are usually low in people with advanced kidney disease.

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