When prescribing iron therapy, balance the potential benefits of avoiding or minimizing blood transfusions, ESA therapy and anemia-related symptoms against the risk of harm in individual patients (e.g., anaphylactoid and other acute reactions, unknown long-term risks)

For adult CKD patients with anemia not on iron or ESA therapy we suggest a trial of IV iron (or in CKD ND patients alternatively a 1-3 month trial of oral iron therapy) if an increase in Hb concentration without starting ESA treatment is desired, AND if TSAT ≤ 30% and Ferritin ≤ 500 ng/mL (Adults & Children > 15 years)

For all pediatric CKD patients with anemia not on iron or ESA therapy, we recommend oral iron (or IV iron in CKD HD patients) administration when TSAT is ≤ 20% and ferritin is ≤ 100 ng/ml (≤100 lg/l).

For adult CKD patients on ESA therapy who are not receiving iron supplementation, we suggest a trial of IV iron (or in CKD ND patients alternatively a 1-3 month trial of oral iron therapy) if an increase in Hb concentration or a decrease in ESA dose is desired, AND if TSAT ≤ 30% and Ferritin ≤ 500 ng/mL (Adults & Children > 15 years)

For all pediatric CKD patients on ESA therapy who are not receiving iron supplementation, we recommend oral iron (or IV iron in CKD HD patients) administration to maintain TSAT >20% and ferritin >100 ng/ml (>100 lg/l)

For Adults & Children > 15 years:

• Trial of IV Iron, or
• Trial of PO Iron x 1-3 months (in CKD ND)

For pediatric CKD patients (Children > 15 years):

• Trial of PO iron, or IV iron in CKD HD

For CKD ND patients who require iron supplementation, select the route of iron administration based on:

• Severity of iron deficiency
• Availability of venous access
• Response to prior oral iron therapy
• Side effects with prior oral or IV iron therapy
• Patient compliance, and
• Cost

For Adults & Children > 15 years:

• Trial of IV Iron, or
• Trial of PO Iron x 1-3 months (in CKD ND)

For pediatric CKD patients (Children > 15 years):

• Trial of PO iron, or IV iron in CKD HD

For CKD ND patients who require iron supplementation, select the route of iron administration based on:

• Severity of iron deficiency
• Availability of venous access
• Response to prior oral iron therapy
• Side effects with prior oral or IV iron therapy
• Patient compliance, and
• Cost

For Adults & Children > 15 years:

• Trial of IV Iron, or
• Trial of PO Iron x 1-3 months (in CKD ND)

For pediatric CKD patients (Children > 15 years):

• Trial of PO iron, or IV iron in CKD HD

For CKD ND patients who require iron supplementation, select the route of iron administration based on:

• Severity of iron deficiency
• Availability of venous access
• Response to prior oral iron therapy
• Side effects with prior oral or IV iron therapy
• Patient compliance, and
• Cost

For Adults & Children > 15 years:

• Trial of IV Iron, or
• Trial of PO Iron x 1-3 months (in CKD ND)

For pediatric CKD patients (Children > 15 years):

• Trial of PO iron, or IV iron in CKD HD

For CKD ND patients who require iron supplementation, select the route of iron administration based on:

• Severity of iron deficiency
• Availability of venous access
• Response to prior oral iron therapy
• Side effects with prior oral or IV iron therapy
• Patient compliance, and
• Cost

Subsequent iron administration in CKD patients should be based on Hb responses to recent iron therapy, as well as ongoing blood losses, iron status tests (TSAT and ferritin), Hb concentration, ESA responsiveness and ESA dose in ESA treated patients, trends in each parameter, and the patient's clinical status.

Evaluate iron status (TSAT and ferritin) at least every 3 months during ESA therapy, including the decision to start or continue iron therapy

Test iron status (TSAT and ferritin) more frequently when initiating or increasing ESA dose, when there is blood loss, when monitoring response after a course of IV iron, and in other circumstances where iron stores may be depleted.

Avoid administering IV iron to patients with active systemic infections

When the initial dose of IV IRON DEXTRAN is administered:

• RECOMMEND that patients be monitored for 60 minutes after the infusion and that resuscitative facilities (including medications) and personnel trained to evaluate and treat serious adverse reactions be available (EVIDENCE GRADE 1B)

When the initial dose of IV NON-IRON DEXTRAN is administered:

• SUGGEST that patients be monitored for 60 minutes after the infusion and that resuscitative facilities (including medications) and personnel trained to evaluate and treat serious adverse reactions be available (EVIDENCE GRADE 2C)

Avoid administering IV iron to patients with active systemic infections

When the initial dose of IV IRON DEXTRAN is administered:

• RECOMMEND that patients be monitored for 60 minutes after the infusion and that resuscitative facilities (including medications) and personnel trained to evaluate and treat serious adverse reactions be available (EVIDENCE GRADE 1B)

When the initial dose of IV NON-IRON DEXTRAN is administered:

• SUGGEST that patients be monitored for 60 minutes after the infusion and that resuscitative facilities (including medications) and personnel trained to evaluate and treat serious adverse reactions be available (EVIDENCE GRADE 2C)