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Functional Iron Deficiency TSAT CKD — ESENeph MCQ

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ModerateChronic Kidney DiseaseFunctional Iron Deficiency TSAT CKDESENeph

A 59-year-old woman with CKD G4 (eGFR 18 mL/min/1.73m2) develops symptomatic anaemia (Hb 82 g/L). Ferritin is 350 ug/L, transferrin saturation (TSAT) 18%, CRP 8 mg/L. She is not on ESA or iron therapy. What is the most appropriate initial management?

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Correct answer: E — Start IV iron supplementation

Despite ferritin of 350 ug/L, the TSAT of 18% indicates functional iron deficiency — there is adequate storage iron but insufficient available iron for erythropoiesis. KDIGO 2025 anaemia guidelines and NICE NG203 recommend IV iron supplementation when TSAT <20%, even with ferritin up to 500 ug/L, to replenish circulating iron. The PIVOTAL trial demonstrated safety of IV iron up to ferritin 700 ug/L in dialysis patients. IV iron should be given first before starting ESA, as iron-deficient patients are ESA-hyporesponsive. A trial of IV iron may itself improve Hb sufficiently without needing ESA.

Reference: KDIGO 2025 – CKD Anaemia Guideline; Macdougall et al 2019 – PIVOTAL Trial; NICE 2021 – NG203