Contemporary pharmacological management of anemia associated with chronic kidney disease

Iron supplementation, erythropoiesis-stimulating agents (ESAs), and hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs) are currently the main therapeutic options for anemia associated with chronic kidney disease (CKD). In 2026, KDIGO published an updated clinical practice guideline for anemia management in CKD.

This review summarizes the recent advances in the pharmacological management of CKD-associated anemia, focusing on iron supplementation, ESAs, and HIF-PHIs.

The 2026 KDIGO Clinical Practice Guideline for the Management of Anemia in Chronic Kidney Disease advocates a more proactive approach to iron supplementation in patients with CKD, based on emerging evidence, and provides guidance on HIF-PHIs, which are increasingly used in clinical practice. Robust evidence regarding the optimal thresholds for initiating iron therapy and target values for iron parameters remains lacking, highlighting the need for treatment strategies tailored to patient and regional characteristics. Although HIF-PHIs have demonstrated efficacy comparable to that of ESAs, concerns remain regarding potential increases in the risks of cardiovascular and thromboembolic events in some patient populations, additionally, their long-term safety regarding malignancy has not been fully established. Further studies are needed to establish individualized treatment strategies and clarify the long-term safety and optimal therapeutic targets for anemia management in patients with CKD.