KDOQI US Commentary on the KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in CKD

The prevalence of anemia is high in people with chronic kidney disease (CKD) and increases as the disease advances. The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the Kidney Disease: Improving Global Outcomes (KDIGO) 2026 clinical practice guideline for the management of anemia in CKD. The previous KDIGO anemia guideline was published in 2012; in 2019 and 2021 KDIGO convened conferences addressing controversies in iron management and hypoxia-inducible factor-prolyl hydroxylase inhibitor (HIF-PHI) use, respectively. The KDOQI work group provides perspective for implementation of the KDIGO 2026 anemia guideline within the context of clinical practice in the United States. The KDOQI work group agrees with most of the KDIGO recommendations, particularly the proactive use of intravenous (IV) iron in hemodialysis patients and the preference for erythropoiesis stimulating agents (ESAs) over HIF-PHIs for first-line anemia therapy, due to greater familiarity with safety of the former. Specific issues regarding recommendations and practice points for providers in the United States include higher serum ferritin targets and mean levels among people receiving hemodialysis than in the rest of the world; the availability of a single HIF-PHI product with approval only for patients receiving dialysis for ≥3 months; and payment barriers that may drive the choice of therapeutic agents. Additional commentary is provided on topics including IV iron therapy in people receiving hemodialysis and an iron-based phosphate binder, the incidence and significance of hypophosphatemia among people with CKD not on dialysis but receiving IV iron therapy, the physiologic importance of iron repletion in people with CKD and iron deficiency without anemia, possible therapeutic benefits of HIF-PHIs compared with ESAs, and assessing risk versus harm of red blood cell transfusions.