A 60-year-old CKD stage 4 (eGFR 22 mL/min) patient has haemoglobin 9.2 g/dL, serum ferritin 95 ng/mL, TSAT 18%. He is not on dialysis. According to KDIGO 2012 CKD anaemia guidelines, what is the preferred next step?
- A Start erythropoiesis-stimulating agent (ESA) immediately targeting Hb 11–12 g/dL
- B Start IV iron to achieve ferritin 200–500 ng/mL and TSAT 20–30% before reassessing ESA need ✓
- C Start oral iron supplementation with ferrous sulphate 200 mg three times daily
- D Transfuse packed red cells to maintain Hb >10 g/dL
Correct answer: B. Start IV iron to achieve ferritin 200–500 ng/mL and TSAT 20–30% before reassessing ESA need
Explanation
KDIGO 2012 recommends optimizing iron stores before initiating ESA therapy in non-dialysis CKD. With TSAT <20% and ferritin <200 ng/mL, iron deficiency (absolute or functional) should be corrected first. IV iron is more effective than oral iron in CKD due to impaired oral iron absorption (hepcidin-mediated sequestration). The target is ferritin 200–500 ng/mL and TSAT 20–30% before reassessing whether ESA is needed. ESA use without correcting iron deficiency is ineffective and increases cardiovascular risk at higher Hb targets (CHOIR, CREATE trials).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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