Nefrologia (Engl Ed). 2026 Jul 7:501576. doi: 10.1016/j.nefroe.2026.501576. Online ahead of print.
ABSTRACT
Anemia in chronic kidney disease (CKD) remains highly prevalent and is strongly associated with increased cardiovascular morbidity, mortality, and impaired quality of life. The Anemia Working Group of the Spanish Society of Nephrology reviews the KDIGO 2026 anemia guideline, structured into 4 chapters, integrating national epidemiological data and the regulatory framework of the Spanish National Health System to contextualize its implementation. The guideline introduces substantial updates, particularly in iron therapy strategies, the role of hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs), and the systematic assessment of treatment resistance. Iron deficiency is reclassified as 'systemic deficiency' or 'iron-restricted erythropoiesis', reinforcing a proactive intravenous iron approach in hemodialysis, supported by the PIVOTAL trial. Broader thresholds for initiating iron therapy in non-dialysis CKD are proposed, although uncertainties persist regarding upper ferritin and transferrin saturation limits. The guideline emphasizes individualized selection of the administration route and recommends withholding iron during systemic infections. Notably, treatment of marked iron deficiency without anemia is now considered. Erythropoiesis-stimulating agents remain first-line therapy once alternative causes are excluded and iron deficiency corrected. Hemoglobin targets remain < 11.5 g/dL, with individualized initiation between 8.5 and 10 g/dL depending on cardiovascular risk, symptoms, and transfusion needs, with slightly lower thresholds in dialysis (≥9-10 g/dL). The guideline stresses using the lowest effective erythropoiesis-stimulating agent or HIF-PHI dose, with adjustments every 4 weeks. HIF-PHIs, such as roxadustat, are reserved for non-dialysis CKD when erythropoiesis-stimulating agents are unsuitable, given potential risks and limited long-term data. Finally, Patient Blood Management strategies are promoted to reduce transfusions, particularly in kidney transplant candidates. This position statement underscores the importance of adapting international recommendations to Spanish clinical practice, prioritizing safety, individualized care, and shared decision-making.
PMID:42414122 | DOI:10.1016/j.nefroe.2026.501576