What are the recommended treatment options for managing anaemia of chronic disease in patients with chronic kidney disease?

Management of anaemia of chronic disease in patients with chronic kidney disease (CKD) involves a multifaceted approach prioritising correction of iron deficiency, use of erythropoiesis-stimulating agents (ESAs), and addressing contributory factors such as secondary hyperparathyroidism. First, iron status should be regularly assessed using appropriate tests like percentage of hypochromic red blood cells, reticulocyte haemoglobin content, or a combination of transferrin saturation and serum ferritin, avoiding reliance on ferritin or transferrin saturation alone ¹.

For patients with iron deficiency who are not on ESA therapy, iron supplementation is recommended before initiating ESAs. Oral iron therapy is considered initially for non-haemodialysis patients, with intravenous iron reserved for those intolerant to oral iron or who do not achieve target haemoglobin levels within 3 months. For patients on haemodialysis, intravenous iron is preferred, with oral iron only if intravenous therapy is contraindicated or declined after discussing risks and benefits ¹.

In patients receiving ESA therapy, concurrent iron supplementation is essential if iron deficiency is present, with intravenous iron preferred for adults and young people, and oral iron considered for children not on haemodialysis unless ineffective or intolerable ¹. Serum ferritin should be monitored to avoid exceeding 800 micrograms/litre, adjusting iron dosing when ferritin reaches 500 micrograms/litre to prevent overload ¹.

ESAs should be offered to patients with anaemia of CKD who are likely to benefit in terms of quality of life and physical function, after ensuring iron deficiency is corrected. Treatment decisions should be individualised, considering comorbidities and prognosis, and involve shared decision-making with patients and carers ¹. Blood transfusions should be avoided if possible, especially in those eligible for kidney transplantation ¹.

Newer therapeutic options such as roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, are recommended for symptomatic anaemia in adults with stage 3 to 5 CKD not on dialysis and without iron deficiency, expanding treatment choices beyond traditional ESAs ¹.

Management also includes treating secondary hyperparathyroidism to improve anaemia control, using agents like cinacalcet or etelcalcetide when indicated ¹. Androgens and supplements such as vitamin C, folic acid, or carnitine are not recommended specifically for anaemia of CKD ¹.

Recent nephrological literature supports this integrated approach, emphasising the importance of correcting iron deficiency to optimise ESA responsiveness and improve patient outcomes (Marques Vidas et al., 2025). It also highlights the evolving role of novel agents like roxadustat in providing alternatives to ESAs, particularly in patients with contraindications or suboptimal response (Bonomini et al., 2023). Furthermore, systematic reviews underline the multifactorial nature of anaemia in CKD, reinforcing the need for comprehensive management including addressing inflammation and comorbidities (Prapaiwong et al., 2025).