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Anaemia of chronic kidney disease with iron deficiency — MSRA MCQ

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HardNephrologyAnaemia of chronic kidney disease with iron deficiencyMSRA

A 68-year-old man with type 2 diabetes and stable CKD G4 attends for review of worsening fatigue and reduced exercise tolerance. His eGFR has been 26–28 mL/min/1.73 m² for 8 months. He is not on dialysis and has never received an erythropoiesis-stimulating agent (ESA). His haemoglobin has fallen from 117 g/L to 96 g/L over 4 months; MCV is 89 fL. White cell count and platelets are normal. CRP is 4 mg/L, vitamin B12 and folate are normal, and recent upper and lower gastrointestinal investigations for iron deficiency were unremarkable. He has no overt bleeding, infection, chest pain, haemodynamic instability or symptoms of heart failure. Ferritin is 72 micrograms/L and transferrin saturation is 17%. What is the most appropriate next management of his anaemia?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Offer a trial of oral iron before considering erythropoiesis-stimulating agent therapy

Explanation lettering: D = shown as B · B = shown as C · E = shown as D · C = shown as E

This man has anaemia requiring management: his haemoglobin is below 110 g/L and he is symptomatic. With eGFR below 30 mL/min/1.73 m², CKD is a likely contributor, although other causes should still be considered; here, relevant alternative causes have been assessed. His transferrin saturation of 17% together with ferritin of 72 micrograms/L meets NICE criteria for iron deficiency in anaemia of CKD when reticulocyte-based measures are unavailable. He is iron deficient, not receiving an ESA and not on haemodialysis. NICE recommends iron replacement before discussing ESA treatment and advises considering a trial of oral iron before intravenous iron in people who are not having haemodialysis. Therefore E is the appropriate sequence. A is incorrect because ESA therapy should not be started in absolute iron deficiency without also managing iron deficiency. B is disproportionate in a stable patient without acute bleeding, cardiovascular ischaemia or haemodynamic compromise; transfusion should be avoided where possible in CKD, particularly when future transplantation could be relevant. C ignores both symptomatic anaemia and demonstrable iron deficiency. D would become appropriate if he could not tolerate oral iron or failed to reach target haemoglobin after 3 months of oral treatment.

Reference: NICE NG203: Chronic kidney disease: assessment and management — diagnosing, assessing and managing anaemia (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations