Iron Needs in Dialysis

National Kidney Foundation's Kidney disease outcomes Quality initiative

Did you know that the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKFKDOQI ™) develops guidelines that help your doctor and health care team make important decisions about your medical treatment? The information in this booklet is based on the NKF-KDOQI recommended guidelines for anemia.

Stages of Chronic Kidney Disease

There are five stages of chronic kidney disease. They are shown in the table below. Your doctor determines your stage of kidney disease based on the presence of kidney damage and your glomerular filtration rate (GFR), which is a measure of your level of kidney function. Your treatment is based on your stage of kidney disease. Speak to your doctor if you have any questions about your stage of kidney disease or your treatment.

Stages of Kidney Disease
Stage Description Glomerular Filtration
Rate (GFR)*
1 Kidney damage (e.g., protein
in the urine) with normal GFR
90 or above
2 Kidney damage with mild
decrease in GFR
60 to 89
3 Moderate decrease in GFR 30 to 59
4 Severe reduction in GFR 15 to 29
5 Kidney failure Less than 15
* Your GFR number tells your doctor how much kidney function you have. As chronic kidney disease progresses, your GFR number decreases.

You may be familiar with the term "anemia" because having anemia is common when you have chronic kidney disease (CKD). Anemia happens when you do not have enough red blood cells. In CKD, kidneys don't make enough of a hormone called erythropoietin (EPO), which your body needs to make red blood cells. When there is not enough EPO, you make fewer red blood cells, and anemia develops. In kidney disease, anemia can happen even before the kidneys fail, and it is very common in people on dialysis.

How do I know if I have anemia?

Although not everyone has the same symptoms, anemia can cause you to:

  • Have little energy for your daily activities
  • Look pale
  • Feel tired or weak
  • Have cold hands and feet
  • Be irritable
  • Have brittle nails
  • Have unusual cravings for odd things like ice or dirt
  • Have a poor appetite
  • Feel dizzy or have headaches
  • Have trouble sleeping
  • Feel short of breath
  • Have trouble thinking clearly
  • Have a rapid heartbeat
  • Feel depressed or "down in the dumps"
  • Have restless leg syndrome — an uncomfortable tingling or crawling feeling in your legs

Your doctor can tell if you have anemia by measuring the hemoglobin (Hb) in your blood. Hemoglobin carries oxygen to all body cells for energy. When you are on dialysis, your hemoglobin should be checked regularly.

What is "on deficiency anemia"?

"Iron deficiency anemia" means anemia because of too little iron in the body. Iron is important in many ways. It is a mineral needed for overall good health and healthy blood cells. Iron helps your body make hemoglobin, which is found in red blood cells. When there is not enough iron, red blood cells won't have enough hemoglobin to carry oxygen.

What causes iron deficiency anemia (IDA )?

Iron is found in many foods, and diet is the major source of iron. Besides not getting enough iron in the diet, other causes of IDA are:

  • Blood loss from accidents, surgery, stomach ulcers, kidney or bladder tumors, cancer or polyps in the intestines or other causes
  • Infection or inflammation in your body
  • Diseases of the bowel that keep iron from being absorbed in the gut

What are other causes of anemia?

  • Too little vitamin B12 or folic acid in your body
  • Diseases like kidney disease, liver disease, HIV/AIDS, lupus (an autoimmune disease) or cancer
  • Diseases that harm or destroy your blood cells, such as sickle cell disease
  • Certain types of anemia can be inherited

Are people on dialysis at risk for not getting enough iron?

Yes. People on dialysis need extra iron because of:

  • Lack of iron-rich foods in your diet

    Some foods that are rich in iron like red meats and beans may be limited in your dialysis diet. Without enough iron-rich foods, you are more at risk for not getting enough iron. Your 8 National Kidney Foundation dietitian can help you choose foods that are good sources of iron, vitamins and other minerals. Check with your dietitian before making any changes in your diet.

  • Blood loss during hemodialysis

    At the end of each hemodialysis treatment, a small amount of blood is usually left behind in the dialyzer (artificial kidney). This can be a source of iron loss over time.

In fact, when you are on dialysis, you will probably need extra iron because you will be taking another anemia medicine that uses up your iron.

A thorough anemia evaluation will be done so that the right management plan can be made for you. Your hemoglobin should be checked regularly to monitor how well your anemia treatment is working.

Iron levels need to be tested as well because iron helps your body make enough hemoglobin. Having enough iron helps you reach and stay in the recommended hemoglobin target range.

How is my iron level tested?

Two important blood tests can tell if you have enough iron. They are called transferrin saturation (TSAT) and ferritin (a form of iron that is stored in the body's tissues).

  • Your TSAT level should be at least 20 percent.
  • Your ferritin level should be at least 100 ng/mL if you are on peritoneal dialysis, and more than 200 ng/mL if you are on hemodialysis.

Iron testing should be done every month until your hemoglobin target is reached. After that, testing every 3 months is recommended if your hemoglobin is stable.

How is anemia treated in people on dialysis?

In people on dialysis, anemia is treated with:

  • Drugs called erythropoiesis stimulating agents (ESAs). ESAs replace the EPO that is low in people with kidney failure, so they can make red blood cells.
  • Extra iron. Diet alone cannot supply enough iron to meet your needs. Extra iron will likely be necessary. In fact, once you start taking ESAs, you will make more red blood cells and your iron supply will be used up faster. When you take an ESA, iron therapy helps to:
    • prevent iron deficiency
    • lessen the amount of ESA needed
    • keep your hemoglobin (Hb) within the target range, which is 11-12

    You may wonder if it is possible to end up with too much iron. The use of ESAs helps reduce the build-up of iron. Regular testing of iron status is done to make sure your iron level is right for the type of dialysis you are having. The amount of iron you need and how it will be given depends upon the type of dialysis you get.

    • If you receive peritoneal dialysis, extra iron can be:
      • Taken orally as a supplement
      • Given IV. (This means "intravenous" or infusion into a vein.)
    • If you receive hemodialysis, the best way to get extra iron is IV through the dialysis machine.


Iron is important in treating anemia. Without enough iron, ESAs are wasted and you will not reach your target Hb.

How will I know if my anemia is getting better?

Generally you will begin to feel better and more able to perform your daily activities. Your dialysis team will check your Hb, ferritin, and TSAT levels and perhaps other lab tests regularly. These test values tell how well you are doing. Your dose of ESAs and iron may need to be changed, depending on how you respond to your treatment.

If you are hospitalized, your anemia therapy should continue.


Ask your doctor or your dialysis care team for the results of your Hb, iron and other important tests. You can keep a record of these lab values to help you stay on target. The Dialysis Lab Log can help you do this. To obtain a copy, ask your dialysis care team or call the National Kidney Foundation at 800.622.9010.

Is IV iron safe?

IV iron is generally quite safe. Be sure to talk with your doctor or other health care professional if you have any questions and tell them about any medicines that you are allergic to. On rare occasions, some people may have a reaction to IV iron. Reactions may include low blood pressure, nausea, vomiting and/or diarrhea. Severe allergic reactions are rare.

Why is it important to treat anemia?

Anemia can cause serious problems with your heart. Treating your anemia is important because:

You will have more energy to do your daily tasks.

  • Your quality of life gets better.
  • Your ability to exercise improves.
  • Your chance of having heart problems is lower.

What other information is available?

The National Kidney Foundation has many booklets to help people on dialysis learn more about kidney disease, its complications like anemia, and its management. Visit or, or call 800.622.9010.

National Kidney Foundation

The National Kidney Foundation (NKF) is dedicated to preventing kidney diseases, improving the health and wellbeing of individuals and families affected by these diseases and increasing the availability of all organs for transplantation.

Through its offices nationwide, the NKF provides early detection screenings and other vital patient and community services. The Foundation conducts extensive public and professional education, advocates for patients through legislative action, promotes organ donation and supports kidney research to identify new treatments.

In 2009 NKF launched a groundbreaking multifaceted collaborative initiative to "End the Wait!" for a kidney transplant in the United States in 10 years by using proven strategies to eliminate barriers to donation and institute best practices across the country.

The NKF relies on individual and corporate donations, foundation and government grants, membership and special events to support its range of programs, services and initiatives.

If you would like more information, please contact us.

© 2015 National Kidney Foundation. All rights reserved. This material does not constitute medical advice. It is intended for informational purposes only. Please consult a physician for specific treatment recommendations.