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Alcohol use disorder — USMLE Step 3 MCQ

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HardPsychiatry (Outpatient Management)Alcohol use disorderUSMLE Step 3

A 63-year-old man with stage 4 CKD, fatigue, hemoglobin 8.8 g/dL, ferritin 72 ng/mL, and transferrin saturation 14% has taken oral ferrous sulfate correctly for 3 months without response. He has no bleeding, infection, or urgent transfusion indication. What is the best next step?

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Correct answer: C — Begin intravenous iron and reassess hemoglobin before considering an ESA

The best answer is “Begin intravenous iron and reassess hemoglobin before considering an ESA”. He has persistent iron-restricted erythropoiesis despite an adequate oral trial. IV iron should replenish substrate before an ESA is considered; ESA decisions then incorporate symptoms, transfusion risk, and shared cardiovascular risk assessment. Correct iron deficiency before initiating an erythropoiesis-stimulating agent.

Reference: KDIGO 2026 Anemia in CKD Guideline: https://kdigo.org/wp-content/uploads/2026/03/KDIGO-2026-Anemia-in-CKD-Guideline-Central-Illustrations.pdf