DIET & NUTRITION 
PATIENT EDUCATION 
OBESITY/WEIGHT MANAGEMENT 
EXERCISE/TRAINING 
LEGAL MATTERS 
GUIDELINES/RECOMMENDATIONS ✅ Guideline Update
The 2026 KDIGO anemia in CKD guideline, the first revision in 14 years, replaces two long-standing iron deficiency classifications, formalizes proactive high-dose IV iron in maintenance hemodialysis, and addresses HIF-PHI positioning for the first time since the class received FDA approval.
Pharmacist Considerations
- KDIGO replaces legacy iron labels with “systemic iron deficiency” and “iron-restricted erythropoiesis”; order sets, clinical documentation, and care transition records will need terminology alignment.
- PIVOTAL trial data support proactive high-dose IV iron in maintenance hemodialysis, reducing ESA requirements without increased infection risk; expect protocol and formulary-level review in dialysis settings.
- Vadadustat (Vafseo) is the only US-available HIF-PHI following daprodustat’s voluntary December 2024 withdrawal; FDA labeling restricts both agents to dialysis patients, with cardiovascular safety signals present in non-dialysis CKD populations.
- ESA hyporesponsiveness in CKD frequently reflects underlying inflammation; evidence does not support that raising hemoglobin alone improves patient outcomes.
Practice Applications
- Flag oral iron orders in hospitalized CKD patients; inpatient absorption is clinically unreliable per guideline commentary.
- Monitor TSAT and ferritin trajectories under proactive iron protocols as dialysis center dosing thresholds are updated.
- Verify vadadustat prescriptions are limited to dialysis patients per FDA labeling; screen for cardiovascular risk factors before dispensing.
- Recognize revised iron deficiency terminology in order sets to maintain continuity across CKD care transitions.
Counseling Anchors
- IV iron dosing in hemodialysis targets reduced ESA dependence, not normalization of iron lab values to a fixed number.
- Oral iron is unlikely to be effective during a hospitalization; patients should not expect their outpatient iron regimen to continue working while admitted.
