A 60-year-old man with known CKD (stage 3b, eGFR 38 mL/min) is started on oral sodium bicarbonate for persistent metabolic acidosis. His hemoglobin is 9.1 g/dL, serum iron 60 μg/dL, TSAT 22%, ferritin 280 ng/mL, reticulocyte count low, and EPO level 18 IU/L (inappropriately low for his degree of anemia). What is the treatment of his anemia?

• A IV iron infusion as the sole treatment
• B Red cell transfusion to Hgb >12 g/dL
• C Oral iron supplementation only
• D Erythropoiesis-stimulating agent (ESA) with target Hgb 11–12 g/dL ✓

Explanation

Anemia of CKD is caused by relative EPO deficiency and is treated with erythropoiesis-stimulating agents (ESAs — epoetin alfa, darbepoetin) when Hgb falls below 10 g/dL and iron stores are replete (TSAT ≥20% and ferritin ≥200 ng/mL in dialysis patients). Per KDIGO 2012 guidelines, the Hgb target on ESA therapy is 10–12 g/dL; targeting higher Hgb (>13 g/dL) increases cardiovascular events (CHOIR and CREATE trials). Iron status must be optimized before/during ESA use. HIF-PHI (hypoxia-inducible factor prolyl hydroxylase inhibitors) like roxadustat are newer oral alternatives.

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

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Written and medically reviewed by the StethoPrep medical team.