In CKD, anemia is most often due to decreased erythropoietin production. What is the most appropriate initial step in management?

• A. Iron therapy only, without evaluating iron stores
• B. Transfusion of red blood cells as first line
• C. Anemia due to micronutrient deficiency
• D. Assess iron status with iron studies and consider ESA if iron adequate

Answer: (D)

In CKD-related anemia, the main issue is decreased erythropoietin, but red blood cell production also depends on having enough iron. Starting an erythropoiesis-stimulating agent without confirming iron availability is unlikely to succeed, and iron given without checking stores can lead to unnecessary treatment or overload.

The best initial step is to assess iron status with iron studies—typically ferritin to gauge stored iron and transferrin saturation (TSAT) to gauge circulating iron. If iron stores are adequate, an ESA can be used to stimulate erythropoiesis. If iron is deficient, iron therapy should be given to replenish stores before or alongside ESA therapy. This approach optimizes response and minimizes risks, including transfusion, iron overload, and ESA resistance.