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Reticulocyte Haemoglobin Content CHr Iron — ESENeph MCQ

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HardChronic Kidney DiseaseReticulocyte Haemoglobin Content CHr IronESENeph

A 50-year-old man with diabetic CKD G4 has a haemoglobin of 92 g/L. His reticulocyte count is elevated (appropriate response to ESA). However, his reticulocyte haemoglobin content (CHr/Ret-He) is low at 25 pg (target >29 pg). What does this indicate?

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Correct answer: C — Functional iron deficiency – the bone marrow is producing red cells (high reticulocytes) but iron supply is insufficient for adequate haemoglobin loading (low CHr); IV iron is needed even if ferritin appears adequate, as iron availability for erythropoiesis is restricted

Reticulocyte haemoglobin content (CHr or Ret-He) is a real-time marker of iron availability for erythropoiesis. A CHr <29 pg indicates that newly produced red cells have insufficient haemoglobin – reflecting functional iron deficiency (iron-restricted erythropoiesis). This can occur even with apparently adequate ferritin if hepcidin-mediated iron sequestration prevents iron mobilisation from stores. KDIGO 2025 and NICE NG8 recognise CHr as a useful tool for guiding iron therapy. It responds within days of IV iron (faster than ferritin or TSAT), making it valuable for monitoring response.

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