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B12 Folate ESA Resistance CKD — ESENeph MCQ

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EasyChronic Kidney DiseaseB12 Folate ESA Resistance CKDESENeph

A 55-year-old man with CKD G4 develops vitamin B12 deficiency (B12 85 pg/mL) with macrocytic anaemia (MCV 108 fL) and Hb 82 g/L. His ESA dose has been increasing without response. What is the importance of checking B12 and folate in ESA-resistant anaemia?

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Correct answer: C — B12 and folate deficiency cause ineffective erythropoiesis, contributing to ESA resistance; correction may restore ESA responsiveness and should be part of the ESA hyporesponsiveness workup

B12 and folate are essential cofactors for DNA synthesis in erythroid precursors. Deficiency causes megaloblastic/macrocytic anaemia and impairs the bone marrow's response to ESA. In the CKD population, B12 deficiency can result from poor nutrition, gastric acid suppression (PPIs reduce B12 absorption), and dialysis-related losses. KDIGO 2025 anemia guideline recommends evaluating B12 and folate as part of the ESA hyporesponsiveness workup. Correction of deficiency often restores ESA responsiveness without needing dose escalation.

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