Objective: - The aim of this study is to explore the usefulness of reticulocyte hemoglobin content (CHr) as one of the important iron indices in detection, treatment and follow up of iron deficiency anemia in patients with end-stage renal disease (ESRD) in comparison with both serum ferritin and transferrin saturation (TSAT).Patients: - The study included 40 patients with ESRD, with renal anemia, on maintenance hemodialysis thrice weekly for at least 2 months before the study, with hematocrite value (Hct) of less than 30%. Twenty-seven of them were males and 13 were females. Their age ranged from 5 years to 18 years old. According to the baseline iron indices, the 40 patients were divided into three groups. In group I; IV iron management was based on TSAT and/or ferritin (IV iron was given if TSAT <30% and/or ferritin <500 ng/ml), in group II; IV iron was based on CHr (IV iron was given if CHr <29 pg), while in group III; patients continued on oral iron. Intra-venous iron in the form of ferric hydroxide saccharate complex was given to patients of both group I and group II, while patients of group III continued on oral iron.Measurements and Results: - Detailed history, complete clinical examination each dialysis session and routine pre- and post-dialysis laboratory investigations were obtained. Iron indices were examined at baseline and followed for the following 5 months. Twenty-three patients reached target Hct. Recombinant human erythropoietin (rHuEpo) eliminated frequent blood transfusion in most of the patients. Patients who did not reach target Hct received a significantly more frequent blood transfusion and also they required significantly higher rHuEpo doses than patients who reached target Hct. Patients of group III needed significantly higher rHuEpo doses. Parathyroid hormone (PTH) and C-reactive protein (CRP) levels were significantly higher in patients who did not reach target Hct. IV iron is important for good response to rHuEpo even in hemodialysis (HD) patients without overt iron deficiency. CHr should be combined with other iron indices for better diagnosis, treatment and follow up of iron deficiency anemia.