Lucia Del Vecchio, Aleix Cases, Michele F Eisenga, Jolanta Małyszko, Jonathan Barratt, Davide Bolignano
The 2026 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in Chronic Kidney Disease represents a substantial update, coming more than a decade since the previous KDIGO guideline on the topic. This time lapse was necessary in order to accumulate new scientific evidence that was meaningful for an updated guideline. The new guideline now includes updated recommendations and practice points for anaemia management, incorporating recent evidence on intravenous iron therapies and hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). This European Renal Best Practice commentary critically evaluates and comments on relevant and newer recommendations and practice points, focusing on key aspects from a European perspective. The new guideline emphasizes the need for a comprehensive evaluation of the patient at the time of diagnosis, to identify additional causes of anaemia other than erythropoietin insufficiency. Coherently, the timing and the type of treatment should be individualized. Moreover, it introduces more proactive thresholds for intravenous iron supplementation, especially for haemodialysis patients. Erythropoiesis-stimulating agents are recommended as the preferred first-line therapy due to persisting concerns regarding cardiovascular safety and methodological limitations of available HIF-PHI trials. The commentary includes considerations on special aspects not considered by the new KDIGO guideline, such as pregnancy, gender-specific considerations, and interactions with sodium-glucose cotransporter 2 inhibitors or inflammation. The commentary also highlights regional regulatory differences between European and US drug approvals for HIF-PHIs. While supporting most recommendations, European nephrologists should consider local contexts, regulatory approvals and emerging evidence when implementing these guidelines in clinical practice.