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).
This 2024 guideline update covers the management of anaemia in adults, children and young people with anaemia associated with CKD. While there is no universally accepted classification for categorising the population with anaemia of CKD by age, this guideline adopts the classification set out in NICE Guideline (4) defined as follows:
- children: 0–13 years
- young people: 14–17 years
- adults: 18 years and over
This guideline has reviewed the additional evidence from July 2016 using systematic literature searches to identify all published clinical evidence relevant to the review questions. Databases were searched for all published papers between July 2016 and May 2023, using relevant medical subject headings, free-text terms and study-type filters where appropriate. All searches were conducted in MEDLINE, PUBMED, Embase, and The Cochrane Library. Data search used the following search terms:
- Anaemia and CKD and the US equivalent terms for “anemia”
- Anaemia and dialysis
- Anaemia and transplantation
- Anaemia and end stage kidney disease and equivalents
- Blood transfusion and dialysis
- Erythropoietin, EPO, ESA
- ESA Resistance
- Ferroportin
- Hepcidin
- Hypoxia inducible factor prolyl hydroxylase
- Hypoxia inducible factor inducers
- hypoxia inducible factor inhibitors, HIF-PHI
- Immunosuppression and anaemia
- Immunosuppression and EPO
- Immunosuppression and blood transfusion
- Iron anaphylaxis
- Iron deficiency
- Iron hypophosphataemia
- Iron therapy
- Iron sensitivity
- Iron toxicity
- SGLT2 inhibitors and anaemia
- SGLT2 inhibitors and Erythropoietin
- Pure red cell aplasia
- Renal anaemia
- Renal transplant and anaemia
- Renal transplant and blood transfusion
- Renal transplant and EPO
Previous guidelines covered the periods prior to the above dates. Articles not written in English were not assessed. Articles available in abstract forms, letters, case reports, editorials or review articles were also excluded. Articles were assessed for relevance to the guideline topic, eligibility for inclusion in the evidence base for that guideline and methodological quality.
Articles were considered of particular relevance if they were describing:
- Prospective randomised or quasi-randomised trials
- Controlled trials
- Meta-analysis of several trials
- Cochrane systematic reviews
Where evidence was available from the above sources, recommendations were based on these publications. Where there was a lack of evidence from high-quality studies, recommendations were based on current consensus from the guideline committee’s experience and opinion of what constitutes good practice and that was made clear in the document:
We also reviewed all related guidelines including those listed below:
- European Renal Best Practice (ERBP) for Anaemia in CKD (5,6)
- Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines for Management of anaemia in CKD (7)
- Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Anaemia in Chronic Kidney Disease (8)
- The National Institute for Health and Care Excellence (NICE) guidelines (ng203) (3)