Nephrology

KDIGO 2026 updates anemia management across the CKD spectrum

The KDIGO 2026 anemia guideline revises recommendations on diagnosis, iron therapy, ESAs, hypoxia-inducible factor–prolyl hydroxylase inhibitors, and transfusion use in CKD. Recommendations are built on systematic reviews with GRADE-based certainty and strength ratings, plus practice points for common clinical scenarios. The document emphasizes actionable guidance for iron and ESA initiation, HIF-PHI use, and transfusion thresholds across nondialysis and dialysis CKD. It also highlights evidence gaps, research priorities, and policy implications relevant to reimbursement and global implementation. 1

Longer ESA treatment in CKD associates with higher osteoporotic fracture risk

This nested case-control study included 19,720 ESA-treated CKD patients in Hong Kong, with 959 major osteoporotic fractures matched to 9,262 controls. Fracture cases had longer ESA treatment duration and higher cumulative defined daily dose than matched controls. Each additional treatment year was independently associated with higher overall fracture risk and higher hip fracture risk. Cumulative ESA dose was not independently associated with fracture, and results were robust to multiple adjustments. These data support minimizing unnecessary ESA exposure duration and considering bone risk surveillance during long-term ESA therapy. 2

SZC approval in Japan linked to less RRT for acute hyperkalemia without higher mortality

This nationwide analysis included 38,540 adult hospitalizations with serum potassium ≥5.5 mmol/L between 2015 and 2024. After sodium zirconium cyclosilicate approval in 2020, the monthly proportion receiving renal replacement therapy for acute hyperkalemia showed a significant decreasing trend. In the post–COVID-19 period, ICU admission rates also declined, while in-hospital mortality and maintenance hemodialysis initiation remained unchanged. These findings suggest broader SZC availability was associated with less intensive rescue therapy without apparent harm in short-term kidney or patient outcomes. 3

Anti-PLA2R antibody trajectories robustly stratify risk in PLA2R-associated membranous nephropathy

Among 1,528 patients with PLA2R-associated membranous nephropathy, four longitudinal anti-PLA2R antibody trajectories were identified: rising, low-stable, declining, and high-stable. The low-stable group had the lowest rates of renal function decline, clinical non-remission, and relapse. Compared with low-stable patients, rising, declining, and high-stable trajectories had significantly higher adjusted hazards of renal function decline and lower remission rates. These higher-risk groups also had increased relapse odds, and associations were consistent across age and sex strata. Serial anti-PLA2R monitoring can therefore inform risk stratification, immunosuppression intensity, and follow-up frequency. 4