A 72-year-old man with CKD stage 4 (eGFR 22) is referred for nephrology care. Fasting blood glucose is 140 mg/dL, haemoglobin 9.8 g/dL with MCV 82, serum ferritin 350 ng/mL, transferrin saturation 18%. Which erythropoiesis-stimulating agent (ESA) consideration is most important here?

• A ESA should be started immediately to target Hb > 13 g/dL
• B Iron status must be optimised (transferrin saturation > 20%) before or alongside ESA initiation; ESA target Hb 10-11.5 g/dL ✓
• C ESAs are contraindicated in CKD stage 4; reserved for dialysis patients only
• D Oral iron alone is sufficient to treat CKD anaemia without ESA in stage 4

Explanation

Before initiating ESA (epoetin or darbepoetin alfa) in CKD anaemia, iron stores must be adequate: transferrin saturation > 20% and ferritin > 100 ng/mL (pre-dialysis). This patient has TSAT 18% (borderline low), indicating functional iron deficiency that will blunt ESA response. IV iron (preferred in CKD ND for better absorption and efficacy) should be given concurrently or before ESA. Per KDIGO guidelines, Hb target with ESA is 10-11.5 g/dL — avoiding normalisation (> 13 g/dL) which increases cardiovascular risk. ESAs are used in CKD pre-dialysis when Hb < 10 g/dL after optimising iron.

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

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Written and medically reviewed by the StethoPrep medical team.