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Anemia of chronic kidney disease with uncontrolled hypertension — ABIM Board MCQ

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HardChronic Kidney DiseaseAnemia of chronic kidney disease with uncontrolled hypertensionABIM Board

A 58-year-old woman with stage G5 chronic kidney disease not receiving dialysis is undergoing evaluation for preemptive kidney transplantation. During the past 4 months, her hemoglobin has declined from 10.1 to 8.7 g/dL. She reports fatigue with routine activity but has no chest pain, dyspnea at rest, syncope, or bleeding. Blood pressure is 184/106 mm Hg and remains 182/104 mm Hg after seated rest. She has no headache, visual changes, neurologic deficits, or pulmonary edema. Laboratory studies show a mean corpuscular volume of 89 fL, reticulocyte count of 0.7%, ferritin of 280 ng/mL, transferrin saturation of 28%, and normal vitamin B12 and folate levels. Testing for hemolysis and occult gastrointestinal bleeding is negative. Which of the following is the most appropriate anemia management strategy?

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

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Correct answer: D — Intensify antihypertensive therapy, then initiate darbepoetin alfa after blood pressure control

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

This patient has hypoproliferative anemia attributable to advanced CKD: the anemia is normocytic, the reticulocyte response is low, and iron deficiency, vitamin deficiency, hemolysis, and bleeding have been excluded. Her hemoglobin is below 10 g/dL and is declining, making an erythropoiesis-stimulating agent (ESA) reasonable to reduce transfusion exposure, particularly because transfusion-associated HLA sensitization could impede kidney transplantation. However, uncontrolled hypertension is a contraindication to darbepoetin and other ESAs. Her blood pressure must therefore be controlled before treatment is started (D). A is incorrect because she is hemodynamically stable, lacks ischemic or severe anemia symptoms, and has a hemoglobin well above the usual restrictive transfusion threshold. Transfusion would also risk allosensitization. B is tempting because her hemoglobin and transplant status support ESA use, but administering it before controlling severe hypertension violates the drug's contraindication and may worsen hypertension. C is incorrect because ferritin and transferrin saturation demonstrate adequate available iron; intravenous iron is not the necessary first intervention. E is incorrect because ESA therapy may be considered in nondialysis CKD when hemoglobin is below 10 g/dL, the trajectory suggests future transfusion risk, and avoiding alloimmunization is a goal. Dialysis initiation is not a prerequisite.

Reference: Aranesp (darbepoetin alfa) Prescribing Information (April 2024) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/103951s5383lbl.pdf Red Blood Cell Transfusion: 2023 AABB International Guidelines (October 12, 2023) — https://jamanetwork.com/journals/jama/article-abstract/2810754 Red blood cell transfusions and the risk of allosensitization in patients awaiting primary kidney transplantation (2014) — https://pubmed.ncbi.nlm.nih.gov/24300013/