When starting erythropoiesis-stimulating agents for CKD anemia, what is a key consideration?

• A. Monitor for hypertension and ensure adequate iron stores; avoid targeting Hb >11 g/dL
• B. Initiate ESA therapy only after Hb falls below 8 g/dL
• C. Target Hb above 13 g/dL
• D. Ignore iron status

Answer: (A)

Starting erythropoiesis-stimulating agents in CKD-related anemia requires two practical guardrails: iron readiness and blood pressure safety. ESAs boost red blood cell production, which depends on having adequate iron stores; if iron is depleted, the response to therapy is poor, so checking and correcting iron (ferritin and TSAT) before and during ESA treatment is essential. ESAs can raise Hb and blood viscosity, which may elevate blood pressure and cardiovascular risk, so monitor BP and adjust the ESA dose to avoid hypertension. To minimize adverse outcomes, keep the Hb target below about 11 g/dL rather than chasing higher levels, since higher targets offer no benefit and increase risk. Approaches that delay ESA therapy until Hb is very low, aim for Hb well above 11, or ignore iron status do not align with safe management.