A 68-year-old man with CKD stage 4 (eGFR 19 mL/min) has hemoglobin 8.4 g/dL, serum ferritin 95 ng/mL, and transferrin saturation 18%. Reticulocyte count is low. Erythropoietin level is inappropriately low for the degree of anemia. KDIGO 2023 guidelines recommend initiating erythropoiesis-stimulating agent (ESA) therapy when:
- A Hemoglobin falls below 10 g/dL after ensuring iron repletion (ferritin >200, TSAT >20%) ✓
- B Hemoglobin falls below 12 g/dL in all CKD patients
- C Symptoms of anemia are present regardless of Hb level
- D Hemoglobin falls below 8 g/dL regardless of iron stores
Correct answer: A. Hemoglobin falls below 10 g/dL after ensuring iron repletion (ferritin >200, TSAT >20%)
Explanation
KDIGO 2023 guidelines recommend initiating ESA therapy in CKD patients with anemia (Hb <10 g/dL) after ensuring adequate iron stores (ferritin >200 ng/mL and TSAT >20% for non-dialysis CKD). Iron deficiency should be corrected first, as ESA response is blunted with iron deficiency. The Hb target while on ESA therapy is 10-11.5 g/dL; targeting >13 g/dL increases cardiovascular events (CHOIR, TREAT trials). HIF-PHI inhibitors (daprodustat, roxadustat) are newer oral alternatives to ESA in CKD anemia.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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