This patient should receive erythropoiesis-stimulating agent (ESA) therapy. He has anemia of chronic kidney disease (CKD), which affects 90% of patients with a glomerular filtration rate less than 25 to 30 mL/min/1.73 m². Erythropoietin is made by interstitial peritubular fibroblasts of the kidney, so patients with reduced kidney function may have low erythropoietin levels; however, erythropoietin resistance also occurs. When patients with reduced kidney function develop anemia, evaluation for other causes is appropriate; in particular, relative iron deficiency is common. If iron stores are adequate and other causes have also been eliminated (such as cobalamin and folate deficiency, gastrointestinal bleeding), the anemia can be attributed to CKD. The routine measurement of erythropoietin levels plays no role in CKD, because this expensive test does not aid in the diagnosis or guide treatment decisions. ESAs should be considered for patients with symptomatic anemia attributable to erythropoietin deficiency when the hemoglobin level is less than 10 g/dL (100 g/L). Patients with CKD must be carefully counseled about the risks of ESAs, which include increased risk of thrombotic and cardiovascular events as well as increased blood pressure. Additionally, clinicians should explain that target hemoglobin values are lower than those used in the past, and that patients must be monitored regularly to titrate the dose to a target hemoglobin level of 10 to 11 g/dL (100-110 g/L).

Transfusions are avoided in patients with CKD unless a compelling reason exists, such as tissue ischemia. Transfusions sensitize patients to HLAs, which complicate kidney transplantation options.

Even though many patients benefit from iron replacement, this man has adequate iron stores, so replacement therapy is not indicated.