Managing Iron Deficiency Anemia in Advanced Chronic Kidney Disease and Dialysis

Iron deficiency is a primary driver of anemia in patients with advanced chronic kidney disease (CKD) and those on dialysis, contributing to poor quality of life, cardiovascular risk, and increased mortality. The pathophysiology is complex, involving both absolute iron deficiency from blood loss and poor intake, and functional deficiency driven by elevated hepcidin, which blocks iron absorption and mobilization. Management strategies differ by clinical context. While oral iron is an option for nondialysis patients, its utility is often limited by poor absorption and gastrointestinal side effects. Intravenous (IV) iron is the standard of care for dialysis patients and those who fail oral therapy, offering effective repletion of iron stores. The landmark PIVOTAL trial has shifted practice by demonstrating that a proactive, high-dose IV iron regimen in hemodialysis patients significantly reduces mortality, cardiovascular events, and the need for erythropoiesis-stimulating agents compared to a reactive approach, without increasing infection rates. However, iron therapy must be individualized, particularly in special circumstances such as active sepsis, where iron administration is typically deferred to avoid worsening the infection. This review covers the principles of diagnosis and treatment of iron deficiency anemia in advanced CKD, comparing iron replacement strategies and addressing complex clinical scenarios.