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Am J Kidney Dis. 2016 Apr;67(4):548-58. doi: 10.1053/j.ajkd.2015.11.012. Epub 2016 Jan 4.

Diagnosis and Management of Iron Deficiency in CKD: A Summary of the NICE Guideline Recommendations and Their Rationale.

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Department of Physiology and Pharmacology, University of Bristol, Bristol, United Kingdom.
Plymouth Hospitals NHS Trust, Plymouth, United Kingdom.
National Clinical Guideline Centre, London, United Kingdom.
Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom.
Abertawe Bro Morgannwg University Health Board, Swansea, Wales, United Kingdom.
Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom.
Kidney Patient Association, West Midlands, United Kingdom.
Heart of England Foundation Trust, Birmingham, United Kingdom. Electronic address:


The UK-based National Institute for Health and Care Excellence (NICE) has updated its guidance on iron deficiency and anemia management in chronic kidney disease. This report outlines the recommendations regarding iron deficiency and their rationale. Serum ferritin alone or transferrin saturation alone are no longer recommended as diagnostic tests to assess iron deficiency. Red blood cell markers (percentage hypochromic red blood cells, reticulocyte hemoglobin content, or reticulocyte hemoglobin equivalent) are better than ferritin level alone at predicting responsiveness to intravenous iron. When red blood cell markers are not available, a combination of transferrin saturation < 20% and ferritin level < 100ng/mL is an alternative. In comparisons of the cost-effectiveness of different iron status testing and treatment strategies, using percentage hypochromic red blood cells > 6% was the most cost-effective strategy for both hemodialysis and nonhemodialysis patients. A trial of oral iron replacement is recommended in people not receiving an erythropoiesis-stimulating agent (ESA) and not on hemodialysis therapy. For children receiving ESAs, but not treated by hemodialysis, oral iron should be considered. In adults and children receiving ESAs and/or on hemodialysis therapy, intravenous iron should be offered. When giving intravenous iron, high-dose low-frequency administration is recommended. For all children and for adults receiving in-center hemodialysis, low-dose high-frequency administration may be more appropriate.


Anemia; National Institute for Health and Care Excellence (NICE); chronic kidney disease (CKD); clinical practice guideline; diagnostic tests; erythropoietin; hemodialysis; hypersensitivity; inflammation; intravenous iron; iron deficiency; iron overload; iron therapy

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