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ESA-Induced Hypertension — ESENeph MCQ

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ModerateChronic Kidney DiseaseESA-Induced HypertensionESENeph

A 65-year-old man with CKD G4 is started on Erythropoiesis-stimulating agent (Darbepoetin alfa). After 4 weeks, his Hb has risen from 85 to 90 g/L. His BP has increased from 135/80 to 155/95 mmHg. What is the relationship?

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Correct answer: E — ESAs can cause or worsen hypertension; BP should be monitored and controlled during ESA therapy, with dose adjustment if needed

Hypertension is a well-recognised adverse effect of ESA therapy, occurring in 20-30% of patients. Mechanisms include increased blood viscosity (rising Hb), endothelin-1-mediated vasoconstriction, and loss of hypoxia-induced vasodilation. KDIGO 2025 anemia guideline recommends monitoring BP during ESA initiation and titration. If hypertension develops, antihypertensive therapy should be optimised. In severe cases, ESA dose reduction or withholding may be needed. This is another reason to avoid targeting Hb >130 g/L.

Reference: KDIGO 2025 – Anemia in CKD; NICE NG8 2021