What are the recommendations for an elderly female with anemia (Hemoglobin 9.3) and impaired renal function (eGFR 57)?

Management of Anemia in an Elderly Female with Hemoglobin 9.3 and eGFR 57

This elderly female requires immediate investigation for the cause of her anemia, iron supplementation to correct the anemia and replenish stores, and consideration of the multifactorial nature of anemia in the setting of chronic kidney disease. 1

Initial Diagnostic Work-Up

Begin the anemia evaluation immediately, as her hemoglobin of 9.3 g/dL is significantly below the threshold of <12 g/dL that triggers investigation in post-menopausal females. 1

Essential Laboratory Tests

• Obtain a complete blood count with red cell indices, reticulocyte count, and iron studies (serum iron, TIBC, ferritin, transferrin saturation) to differentiate iron deficiency from anemia of chronic disease. 2
• Check inflammatory markers (CRP or ESR) to interpret ferritin levels, as ferritin is an acute phase reactant that can be falsely elevated by inflammation. 2
• Measure vitamin B12 and folate levels, as deficiencies are common in the elderly and often coexist with iron deficiency. 1, 2
• Screen for occult gastrointestinal blood loss if history suggests it, though routine fecal occult blood testing is not recommended due to poor sensitivity and specificity. 1

Understanding the Dual Pathology

With an eGFR of 57 mL/min/1.73m², this patient has Stage 3a CKD, where anemia becomes increasingly prevalent. 1, 3 Iron deficiency is a major contributor to anemia in CKD, with 60.4% of men and 81.3% of women with CKD and anemia having low iron test results when checked. 4

The causes of anemia in elderly patients with CKD are typically multifactorial, including iron deficiency, reduced erythropoietin production, chronic inflammation, poor diet, reduced iron absorption, occult blood loss, and medication effects (especially aspirin/anticoagulants). 1

Gastrointestinal Investigation

Because this patient is elderly (>45 years), she requires investigation of both the upper and lower gastrointestinal tract to exclude malignancy and other pathology, unless a firm cause is identified with the first investigation. 1

Recommended Investigations

• Perform upper GI endoscopy with small bowel biopsy to exclude coeliac disease, gastric/duodenal pathology, and assess for occult bleeding sources. 1
• Perform colonoscopy or, if the patient has significant comorbidities or frailty, consider CT colonography as a less invasive alternative. 1
• The risks and benefits of invasive endoscopic investigations should be carefully weighed in elderly patients with major comorbidities or limited performance status, but investigation should not be automatically deferred based on age alone. 1

The prevalence of dual unrelated pathology increases with age, strengthening the case for imaging both upper and lower GI tract even if one lesion is found. 1

Iron Supplementation Strategy

All patients with confirmed iron deficiency anemia should receive iron supplementation to correct anemia and replenish body stores, regardless of the underlying cause. 1

Oral Iron as First-Line

• Start with ferrous sulphate 200 mg three times daily (or equivalent ferrous gluconate or ferrous fumarate), which is the most simple and cost-effective approach. 1
• Consider adding ascorbic acid if response is poor, as it enhances iron absorption. 1
• Expect hemoglobin to rise by 2 g/dL after 3-4 weeks; failure to respond suggests poor compliance, misdiagnosis, continued blood loss, or malabsorption. 1
• Continue iron supplementation for three months after correction of anemia to replenish iron stores. 1

When to Use Intravenous Iron

Parenteral iron should be used when there is intolerance to at least two oral preparations or documented non-compliance. 1 However, in the context of CKD, intravenous iron has specific advantages:

• Intravenous iron (such as ferric carboxymaltose 1000 mg or iron sucrose 200-300 mg monthly) is more effective than oral iron in CKD patients, achieving greater hemoglobin increases and better iron store repletion. 5, 6
• Intravenous iron in pre-dialysis CKD patients can ameliorate anemia without erythropoiesis-stimulating agents in approximately one-third of patients. 6
• Treatment-related adverse events are significantly fewer with modern intravenous iron preparations compared to oral iron (2.7% vs 26.2%). 5

Given her eGFR of 57 and the high prevalence of functional iron deficiency in CKD (ferritin >100 μg/L but transferrin saturation <20%), intravenous iron may be preferred if iron studies confirm functional iron deficiency. 1, 2

Monitoring and Follow-Up

• Recheck hemoglobin and iron indices at 3-4 weeks to assess response to iron therapy. 1
• Once hemoglobin normalizes, monitor hemoglobin and red cell indices every three months for one year, then annually. 1
• Give additional oral iron if hemoglobin or MCV falls below normal; check ferritin in doubtful cases. 1
• Further investigation is only necessary if hemoglobin and MCV cannot be maintained with iron supplementation. 1

Critical Pitfalls to Avoid

• Do not assume normal ferritin excludes iron deficiency in the presence of inflammation or chronic disease, as ferritin is an acute phase reactant. 2
• Do not start empiric iron supplementation without confirming the diagnosis with appropriate laboratory testing. 2
• Do not overlook combined deficiencies (iron, B12, folate) which are common in elderly patients. 1, 2
• Do not defer investigation based solely on advanced age; the appropriateness should be based on comorbidities, performance status, and whether results would influence management. 1

Prognosis and Outcomes

Lower hemoglobin levels are independently associated with increased risk of cardiovascular disease, coronary heart disease, stroke, heart failure, and death in CKD patients. 4 Effective treatment of anemia in CKD improves survival, decreases morbidity, and increases quality of life. 1

Resolution of anemia should be achieved by six months in 80% of patients with appropriate investigation and treatment. 1