A 72-year-old patient with stage 5 chronic kidney disease on thrice-weekly haemodialysis has a haemoglobin of 86 g/L and low erythropoietin levels, with iron stores in range and no signs of active bleeding. Which treatment should be initiated first?

• A. Blood transfusion
• B. Epoetin alfa
• C. Oral iron supplementation
• D. Vitamin B12

Answer: (B)

Anemia in chronic kidney disease is mainly due to reduced endogenous erythropoietin production. In patients on dialysis, the primary treatment is an erythropoiesis-stimulating agent to stimulate red-cell production, with iron status made sure to be adequate for new red cells.

This patient has low erythropoietin levels and adequate iron stores with no active bleeding, so supplying the missing hormone signal directly addresses the deficit. Starting epoetin alfa will promote erythropoiesis and raise the hemoglobin toward the target range.

A blood transfusion is generally reserved for urgent symptoms or when ESA therapy fails to correct anemia, and it carries risks like alloimmunization and infection, so it’s not the first step here. Oral iron is unnecessary since iron stores are already in range. Vitamin B12 would be indicated only if there were a deficiency, which isn’t indicated in this case.

After starting the ESA, monitor hemoglobin and iron indices regularly and adjust the dose to avoid overshoot, aiming for a safe target concentration.