Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Diagnostic evaluation and assessment of anaemia

  • Carry out testing to diagnose iron deficiency and determine potential responsiveness to iron therapy and long‑term iron requirements every 3 months (every 1–3 months for people receiving haemodialysis).

    • Use percentage of hypochromic red blood cells (% HRC; more than 6%), but only if processing of blood sample is possible within 6 hours.

    • If using percentage of hypochromic red blood cells is not possible, use reticulocyte haemoglobin (Hb) content (CHr; less than 29 pg) or equivalent tests – for example, reticulocyte Hb equivalent.

    • If these tests are not available or the person has thalassaemia or thalassaemia trait, use a combination of transferrin saturation (less than 20%) and serum ferritin measurement (less than 100 micrograms/litre). [new 2015]

  • Do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status in people with anaemia of chronic kidney disease (CKD). [new 2015]

Assessment and optimisation of erythropoiesis

Benefits of treatment with erythropoietic stimulating agents

  • Offer treatment with erythropoietic stimulating agents (ESAs) to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function. [2006]

Optimal Hb levels

  • The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD.

    • Typically[1] maintain the aspirational Hb range between 100 and 120 g/litre for adults, young people and children aged 2 years and older, and between 95 and 115 g/litre for children younger than 2 years of age, reflecting the lower normal range in that age group.

    • To keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 5 g/litre of the range's limits). [2011, amended 2015]

ESAs: monitoring iron status during treatment

  • Offer iron therapy to people[2] receiving ESA maintenance therapy to keep their[3]:

    • percentage of hypochromic red blood cells less than 6% (unless serum ferritin is greater than 800 micrograms/litre)

    • reticulocyte Hb count or equivalent tests above 29 pg (unless serum ferritin is greater than 800 micrograms/litre)

    • transferrin saturation level above 20% and serum ferritin level above 100 micrograms/litre (unless serum ferritin is greater than 800 micrograms/litre).

      The marker of iron status should be monitored every 1–3 months in people receiving haemodialysis.

      In people who are pre‑dialysis[4] or receiving peritoneal dialysis, levels are typically monitored every 3 months. If these people have a normal full blood count there is little benefit in checking iron status. [new 2015]

Iron therapy for people who are iron deficient and not on ESA therapy

  • Offer iron therapy to people[2] with anaemia of CKD who are iron deficient and who are not receiving ESA therapy, before discussing ESA therapy.

    • Discuss the risks and benefits of treatment options. Take into account the person's choice.

    • For people who are not receiving haemodialysis, consider a trial of oral iron before offering intravenous iron therapy. If they are intolerant of oral iron or target Hb levels are not reached within 3 months, (see recommendation 1.3.11) offer intravenous iron therapy.

    • For people who are receiving haemodialysis, offer intravenous iron therapy. Offer oral iron therapy to people who are receiving haemodialysis only if:

      • intravenous iron therapy is contraindicated or

      • the person chooses not to have intravenous iron therapy after discussing the relative efficacy and side effects of oral and intravenous iron therapy. [new 2015]

  • Discuss the results of the iron therapy with the person or, where appropriate, with their family or carers and offer ESA therapy if needed (see recommendation 1.3.1). [new 2015]

Iron therapy for people who are iron deficient and receiving ESA therapy

  • Offer iron therapy to people[2] with anaemia of CKD who are iron deficient and who are receiving ESA therapy.

    • Discuss the risks and benefits of treatment options. Take into account the person's choice.

    • For adults and young people, offer intravenous iron therapy.

    • For children who are receiving haemodialysis, offer intravenous iron therapy.

    • For children who are not receiving haemodialysis, consider oral iron. If the child is intolerant of oral iron or target Hb levels are not reached within 3 months (see recommendation 1.3.11), offer intravenous iron therapy. [new 2015]

  • When offering intravenous iron therapy to people not receiving haemodialysis, consider high‑dose low‑frequency[5] intravenous iron as the treatment of choice for adults and young people when trying to achieve iron repletion. Take into account all of the following:

    • preferences of the person with anaemia of CKD or, where appropriate, their family or carers

    • nursing and administration costs

    • cost of local drug supply

    • provision of resuscitation facilities.

      Intravenous iron administered at a low dose and high frequency[6] may be more appropriate for all children[2] and for adults who are receiving in‑centre haemodialysis. [new 2015]



[1] The Medicines and Healthcare products Regulatory Agency (MHRA) guidance (2007) notes that using ESAs to achieve Hb levels greater than 120 g/litre is associated with an increased risk of death and serious cardiovascular events in people with CKD. The MHRA advises that Hb levels greater than this should be avoided, and that patients should be monitored closely to ensure that the lowest approved dose of ESA is used to provide adequate control of the symptoms of anaemia. Use of ESAs to achieve Hb levels greater than 120 g/litre is not consistent with UK marketing authorisations for ESAs. If such use is considered, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[2] Refer to the Summary of Product Characteristics for the prescription of individual iron preparations. In particular, note that, at the time of publication (June 2015), intravenous iron products available in the UK did not have a UK marketing authorisation for all ages of children and young people for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Note that the marketing authorisation for ferumoxytol in the EU was withdrawn by the manufacturer in March 2015.

[3] See recommendation 1.1.3 for tests of choice to determine iron deficiency.

[4] There is no accepted definition of pre‑dialysis. It is usually regarded to be CKD stages 4 and 5. Pre‑dialysis includes people with a failing transplant and people having conservative management.

[5] The Guideline Development Group considered this to be a maximum of 2 infusions. For adults, the GDG considered there would be a minimum of 500 mg of iron in each infusion. Refer to the Summary of Product Characteristics for the prescription of individual iron preparations.

[6] The Guideline Development Group considered this to be more than 2 infusions. For adults, the GDG considered there would typically be 100 to 200 mg of iron in each infusion. Refer to the Summary of Product Characteristics for the prescription of individual iron preparations.

  • National Institute for Health and Care Excellence (NICE)