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Anemia of CKD — USMLE Step 3 MCQ

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HardInternal Medicine (Chronic Management)Anemia of CKDUSMLE Step 3

A 69-year-old with stage G4 CKD not receiving dialysis has fatigue and hemoglobin of 8.9 g/dL. Ferritin is 220 ng/mL, transferrin saturation 28%, reticulocyte response is low, B12 and folate are normal, and no blood loss is found. After discussing stroke, thrombosis, transfusion avoidance, and symptom goals, what is the best next step?

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Correct answer: A — Consider an erythropoiesis-stimulating agent using individualized risks and symptom goals

The best answer is “Consider an erythropoiesis-stimulating agent using individualized risks and symptom goals”. After correctable causes and iron deficiency are addressed, ESA initiation in nondialysis CKD is individualized based on symptoms, hemoglobin, transfusion risk, and adverse-event risk. Therapy is not used to normalize hemoglobin because higher targets increase cardiovascular and thrombotic harm.

Reference: KDIGO Clinical Practice Guideline for Anemia in CKD: https://kdigo.org/guidelines/anemia-in-ckd/