This National Institute for Health and Care Excellence (NICE) guideline covers diagnosing, assessing, managing and monitoring anaemia in people with chronic kidney disease. It aims to improve care for people with chronic kidney disease by specifying how to assess when their anaemia needs treating, and by making detailed recommendations on treatment with erythropoietic stimulating agents (ESAs) and iron. It also covers detecting and managing ESA-resistant anaemia.
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. 
Optimal Hb levels
- The correction to normal levels of Hb with ESAs is not usually recommended in people with anaemia of CKD.
- Typically 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 receiving ESA maintenance therapy to keep their:
- 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 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 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, 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
- 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. [new 2015]
Iron therapy for people who are iron deficient and receiving ESA therapy
- Offer iron therapy to people 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, offer intravenous iron therapy. [new 2015]
- When offering intravenous iron therapy to people not receiving haemodialysis, consider high‑dose low‑frequency 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 may be more appropriate for all children and for adults who are receiving in‑centre haemodialysis. [new 2015]
The guideline development group for this 2015 update considered the evidence in several areas that provide challenges for clinicians managing anaemia of CKD. Recombinant human erythropoietin (also called EPO, an erythropoietic stimulating agent or ESA) for treating anaemia of CKD is an important tool in managing the condition. But some CKD patients with anaemia who are offered an ESA are 'ESA resistant' – that is, their condition consistently fails to respond to the ESA treatment. These patients often receive large doses of ESA, sometimes with blood transfusion, with limited benefits and at significant cost to the NHS. Many CKD patients with anaemia receiving an ESA are admitted with an intercurrent illness – such as pneumonia – which may temporarily render them acutely hyporesponsive to that ESA. There is uncertainty about the management of these groups of patients, and these areas were considered in the update. The update once again highlighted the often limited trial evidence in nephrology, compared with other specialities.
Over the past decade attention has shifted to the role and management of iron deficiency in anaemia of CKD. In CKD patients there is often a complex inflammatory state that makes it difficult to diagnose iron deficiency when using its standard markers, such as serum iron, serum total iron binding capacity or ferritin. In recent years evidence has been published on newer markers of iron deficiency and intravenous iron preparations. In this 2015 update, the guideline development group reassessed the diagnosis and management of iron deficiency in CKD, and made several recommendations in these areas.
You can read the guideline on NICE's website.