A 50-year-old man with chronic kidney disease (stage 5, on dialysis) has Hb 8.2 g/dL, MCV 88 fL, serum ferritin 320 ng/mL, TSAT 25%, and reticulocyte count 1.2%. What is the primary mechanism of his anemia?

• A Iron deficiency from chronic blood loss during dialysis
• B B12 deficiency from dietary restriction
• C Hemolysis from uremic toxins
• D Decreased erythropoietin production by the kidneys ✓

Explanation

Anemia of chronic kidney disease is primarily due to inadequate erythropoietin production by the diseased kidneys. The anemia is typically normocytic normochromic with low reticulocyte count. Ferritin and TSAT are adequate here, ruling out iron deficiency. ESA therapy is the mainstay, with iron supplementation only if functional or absolute iron deficiency is documented.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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