Anemia is a common complication in chronic kidney disease (CKD) patients, significantly impacting their quality of life and clinical outcomes. The pathophysiology of anemia in CKD involves multiple factors, including erythropoietin (EPO) deficiency, iron dysregulation, chronic inflammation, bone marrow dysfunction, and nutritional deficiencies. Despite advancements in understanding, anemia remains a significant clinical challenge. Guidelines have been developed to standardize diagnostic approaches and treatments, but recommendations vary due to emerging data. Recent studies highlight the potential of novel biomarkers for evaluating anemia and related conditions, such as iron deficiency. The article provides a comprehensive review of the pathophysiology of anemia in CKD, including the role of EPO, iron, inflammation, bone marrow dysfunction, and vitamin deficiencies. It also discusses the diagnosis and management of anemia, focusing on the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation. Additionally, the article explores emerging therapeutic approaches, such as hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs), which target the HIF pathway to stimulate endogenous EPO production and improve iron utilization. Key points include: - EPO deficiency is a primary cause of renal anemia, with CKD patients often having inadequate EPO levels. - Iron dysregulation and inflammation contribute to anemia, with elevated levels of inflammatory biomarkers and hepcidin affecting iron absorption and utilization. - Bone marrow dysfunction and vitamin deficiencies, such as vitamin B12 and folic acid, further complicate anemia management. - Novel biomarkers, such as soluble transferrin receptor (sTfR), hepcidin, neutrophil-gelatinase-associated lipocalin (NGAL), and bone metabolic biomarkers, have shown promise in evaluating anemia and related conditions. - HIF-PHIs, particularly roxadustat, have demonstrated clinical efficacy and safety in managing anemia in CKD patients, offering a promising alternative to traditional treatments. Understanding these complex mechanisms is crucial for developing targeted and effective diagnostic and treatment strategies for anemia in CKD patients.Anemia is a common complication in chronic kidney disease (CKD) patients, significantly impacting their quality of life and clinical outcomes. The pathophysiology of anemia in CKD involves multiple factors, including erythropoietin (EPO) deficiency, iron dysregulation, chronic inflammation, bone marrow dysfunction, and nutritional deficiencies. Despite advancements in understanding, anemia remains a significant clinical challenge. Guidelines have been developed to standardize diagnostic approaches and treatments, but recommendations vary due to emerging data. Recent studies highlight the potential of novel biomarkers for evaluating anemia and related conditions, such as iron deficiency. The article provides a comprehensive review of the pathophysiology of anemia in CKD, including the role of EPO, iron, inflammation, bone marrow dysfunction, and vitamin deficiencies. It also discusses the diagnosis and management of anemia, focusing on the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation. Additionally, the article explores emerging therapeutic approaches, such as hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs), which target the HIF pathway to stimulate endogenous EPO production and improve iron utilization. Key points include: - EPO deficiency is a primary cause of renal anemia, with CKD patients often having inadequate EPO levels. - Iron dysregulation and inflammation contribute to anemia, with elevated levels of inflammatory biomarkers and hepcidin affecting iron absorption and utilization. - Bone marrow dysfunction and vitamin deficiencies, such as vitamin B12 and folic acid, further complicate anemia management. - Novel biomarkers, such as soluble transferrin receptor (sTfR), hepcidin, neutrophil-gelatinase-associated lipocalin (NGAL), and bone metabolic biomarkers, have shown promise in evaluating anemia and related conditions. - HIF-PHIs, particularly roxadustat, have demonstrated clinical efficacy and safety in managing anemia in CKD patients, offering a promising alternative to traditional treatments. Understanding these complex mechanisms is crucial for developing targeted and effective diagnostic and treatment strategies for anemia in CKD patients.