Erythropoiesis-stimulating agents, intravenous iron and potassium binders in kidney disease
Why CKD causes anaemia (erythropoietin deficiency, hepcidin-driven iron restriction), how ESAs, IV iron preparations and HIF-PH inhibitors work and harm, the Hb ceiling from CHOIR, CREATE and TREAT, and the exchange mechanisms, onset and adverse effects of polystyrene sulfonate, patiromer and sodium zirconium cyclosilicate.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- CKD anaemia is normocytic and hypoproliferative: reduced erythropoietin (EPO) from peritubular fibroblasts plus iron restriction from raised hepcidin. Blood loss on dialysis adds absolute iron deficiency.
- Iron first, then an ESA if Hb is still low. KDIGO 2026 recommends against targeting normal Hb and sets a ceiling of 115 g/L on an ESA.
- IV iron bypasses hepcidin's block on gut absorption. Preparations differ in dose size, infusion time and the hypophosphataemia of ferric carboxymaltose.
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Sources
- KDIGO 2026 Clinical Practice Guideline for the Management of Anemia in Chronic Kidney DiseaseKidney Disease Improving Global Outcomes (Kidney International 2026;109(1S)), 2026
- KHA-CARI Guidelines (anaemia and dialysis guidance)AU/NZKidney Health Australia, Caring for Australasians with Renal Impairment, online, checked November 2026
- Australian Medicines HandbookAU/NZAustralian Medicines Handbook Pty Ltd, 2026
- Sodium zirconium cyclosilicate (Lokelma): PBAC Public Summary Document, March 2024, and PBS medicine status pageAU/NZPharmaceutical Benefits Scheme, Australian Government, status checked November 2026 (recommended, not listed)
- Intravenous iron in patients undergoing maintenance hemodialysis (PIVOTAL). N Engl J Med 2019;380:447-58Macdougall et al., 2019
- A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease (TREAT). N Engl J Med 2009;361:2019-32Pfeffer et al., 2009
- Last updated
- 14 November 2026
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