Skill Checkup: A 59-Year-Old Man With a 4-Year History of Non-Dialysis Chronic Kidney Disease Presents With Anemia

Vecihi Batuman, MD, FASN


September 09, 2022

Historically, treatment with EPO was restricted to patients on dialysis with very low Hgb, with the goal of reducing red blood cell transfusion rates. But now, ESAs have become a staple for the management of iron deficiency anemia in patients with CKD and are used among patients with CKD-ND (if Hgb drops < 10 g/dl). In patients who are on dialysis, ESAs are usually avoided unless the Hgb level is between 9 and 10 g/dL. Given the patient's Hbg level is 9.7 g/dl, they qualify for this treatment.

Of note, repletion of iron stores is necessary in patients with CKD to treat iron deficiency and maximize the efficacy of ESAs. Ultimately, the decision to initiate ESA therapy should be individualized on the basis of Hgb concentration, prior response to iron therapy, the likelihood of needing a transfusion, the risks related to ESA therapy, and the presence of anemia.

Although ESAs have been shown to normalize Hgb in patients with CKD, they may also worsen cardiovascular outcomes; therefore, for patients with CKD, current guidelines recommend a target Hgb below the normal level. The Food and Drug Administration label for ESA in the United States outlines the risks for adverse cardiovascular events with dosage > 11 g/dl, advising not to initiate ESA treatment in patients with Hgb > 10 g/dl, and recommending that the lowest possible dose should be used to avoid red blood cell transfusions.

Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.