Iron Deficiency in Chronic Kidney Disease: Updates on Pathophysiology, Diagnosis, and Treatment

J Am Soc Nephrol. 2020 Mar;31(3):456-468. doi: 10.1681/ASN.2019020213. Epub 2020 Feb 10.


Anemia is a complication that affects a majority of individuals with advanced CKD. Although relative deficiency of erythropoietin production is the major driver of anemia in CKD, iron deficiency stands out among the mechanisms contributing to the impaired erythropoiesis in the setting of reduced kidney function. Iron deficiency plays a significant role in anemia in CKD. This may be due to a true paucity of iron stores (absolute iron deficiency) or a relative (functional) deficiency which prevents the use of available iron stores. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood losses, impaired iron absorption, and chronic inflammation. The traditional biomarkers used for the diagnosis of iron-deficiency anemia (IDA) in patients with CKD have limitations, leading to persistent challenges in the detection and monitoring of IDA in these patients. Here, we review the pathophysiology and available diagnostic tests for IDA in CKD, we discuss the literature that has informed the current practice guidelines for the treatment of IDA in CKD, and we summarize the available oral and intravenous (IV) iron formulations for the treatment of IDA in CKD. Two important issues are addressed, including the potential risks of a more liberal approach to iron supplementation as well as the potential risks and benefits of IV versus oral iron supplementation in patients with CKD.

Keywords: anemia; chronic kidney disease; iron.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Administration, Oral
  • Anemia, Iron-Deficiency / diagnosis
  • Anemia, Iron-Deficiency / drug therapy
  • Anemia, Iron-Deficiency / epidemiology*
  • Comorbidity
  • Epoetin Alfa / therapeutic use
  • Female
  • Ferritins / blood
  • Humans
  • Infusions, Intravenous
  • Iron Compounds / therapeutic use*
  • Male
  • Prevalence
  • Prognosis
  • Renal Dialysis / adverse effects*
  • Renal Dialysis / methods
  • Renal Insufficiency, Chronic / diagnosis
  • Renal Insufficiency, Chronic / epidemiology*
  • Renal Insufficiency, Chronic / therapy
  • Risk Assessment
  • Severity of Illness Index
  • Treatment Outcome
  • United States


  • Iron Compounds
  • Epoetin Alfa
  • Ferritins