A 62-year-old woman comes to the office due to fatigue and lethargy over the last 6 months. She has a history of chronic kidney disease due to long-standing type 2 diabetes mellitus and hypertension. Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, pulse is 84/min, and respirations are 16/min. There is conjunctival pallor. The lung fields are clear, and no murmurs are heard on cardiac examination. The abdomen is nontender. Test of the stool for occult blood is negative. Laboratory results are as follows: Which of the following is the best next step in management of this patient's anemia?

Question

A 62-year-old woman comes to the office due to fatigue and lethargy over the last 6 months.  She has a history of chronic kidney disease due to long-standing type 2 diabetes mellitus and hypertension.  Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, pulse is 84/min, and respirations are 16/min.  There is conjunctival pallor.  The lung fields are clear, and no murmurs are heard on cardiac examination.  The abdomen is nontender.  Test of the stool for occult blood is negative.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient's anemia?

Quizplus · Accepted Answer

Explanation: Patients with advanced chronic kidney disease (CKD) or end-stage renal disease commonly develop a hypoproliferative, normocytic, normochromic anemia due to underproduction of erythropoietin (EPO) by the failing kidneys. When anemia is identified in patients with CKD, iron levels should be checked for several reasons: Correctable causes of anemia should be identified; therefore, a basic workup for new anemia should be performed, including evaluation of iron stores, folate and B₁₂ levels, and reticulocyte count, as well as testing for fecal occult blood. In patients with CKD, iron deficiency is common, and red blood cell morphology may be normal early in the deficiency (with a normal mean corpuscular volume). Some patients may require iron supplementation based on low transferrin saturation and ferritin levels. CKD-related hypoproliferative anemia is often treated with EPO-stimulating agents (ESAs), such as supplemental EPO, to stimulate red blood cell production within the bone marrow. However, vigorous hematopoiesis after ESA administration can cause rapid depletion of iron stores, even if iron levels are normal on initiation; therefore, patients who require ESAs (eg, many CKD patients with hemoglobin <10 g/dL) should have iron levels checked prior to initiation of EPO and at scheduled intervals while on therapy (Choice D). (Choice B) Bone marrow biopsy is rarely indicated in the workup of anemia unless abnormal cells (blasts) or pancytopenia is noted. Most common forms of anemia (including CKD-related hypoproliferative anemia) can be evaluated by laboratory tests alone. (Choice C) Serum protein electrophoresis is part of the workup for multiple myeloma; patients typically have new renal dysfunction, anemia, hypercalcemia, and bone pain. This patient has chronic CKD due to her known diabetes and hypertension and does not have hypercalcemia or pain, making this diagnosis unlikely. (Choice E) Low serum folate and B₁₂ levels cause a macrocytic anemia, not a normocytic anemia as seen in this patient. These levels should be checked, but empiric supplementation is not indicated without laboratory-documented deficiency. ₁₂ Educational objective: Patients with advanced chronic kidney disease or end-stage renal disease commonly develop a normocytic anemia due to underproduction of erythropoietin by the failing kidneys. Vigorous hematopoiesis after administration of erythropoiesis-stimulating agents (ESAs) can lead to rapid depletion of iron stores; therefore, all patients who require ESAs should have iron levels checked prior to initiation and at scheduled intervals while on therapy.

A 62-Year-Old Woman Comes to the Office Due to Fatigue