How to manage anemia in an elderly female with complex medical history including CKD (chronic kidney disease), hypertension, CAD (coronary artery disease), HFpEF (heart failure with preserved ejection fraction), type II diabetes mellitus, hyperlipidemia, GERD (gastroesophageal reflux disease), bilateral carotid artery occlusion, prior hemorrhagic stroke, and history of breast and esophageal cancer, presenting with low RBC (red blood cell count), Hgb (hemoglobin), and Hct (hematocrit), and impaired renal function?

Management of Anemia in Elderly Female with CKD and Multiple Comorbidities

This patient requires intravenous iron therapy as first-line treatment for her anemia, given her CKD stage 3b (GFR 38), heart failure with preserved ejection fraction (HFpEF), and functional iron deficiency (ferritin 236, TIBC 190, transferrin saturation ~35%). 1

Initial Assessment and Diagnosis

This patient presents with normocytic anemia (MCHC 32.5, RDW 16.5) in the context of CKD stage 3b, which is the primary driver of her anemia. 2, 3

Key laboratory findings indicate:

• Hemoglobin 8.16 g/dL represents moderate anemia requiring intervention 2
• GFR 38 mL/min/1.73m² places her at high risk for anemia of CKD, as anemia prevalence increases substantially when GFR falls below 60 3, 4
• Iron studies show functional iron deficiency: while ferritin is 236 ng/mL (not absolutely deficient), the TIBC of 190 suggests impaired iron utilization typical of chronic disease 2, 3
• Normal B12 (388) and folate (32.9) exclude nutritional megaloblastic anemia 2
• Hypoalbuminemia (2.9) suggests chronic inflammation or malnutrition, contributing to anemia 3

Primary Treatment Strategy

Initiate intravenous iron therapy immediately rather than oral iron, as this patient has heart failure and CKD—two conditions where IV iron is superior. 1

• The European Heart Journal recommends IV iron as first-line in heart failure patients with functional iron deficiency, which improves symptoms, quality of life, and functional capacity 1
• Target ferritin approximately 100-300 ng/mL with transferrin saturation >20% 2, 1
• A typical regimen is 200 mg IV iron weekly for 3 weeks, then reassess hemoglobin and iron studies 2 months later 2
• Oral iron is ineffective in this population due to hepcidin elevation from chronic inflammation and heart failure 3, 1

Erythropoiesis-Stimulating Agent (ESA) Considerations

Do NOT initiate ESA therapy at this time given her history of hemorrhagic stroke and active malignancy history (breast and esophageal cancer). 2, 5

• KDIGO guidelines recommend using ESAs "with great caution, if at all" in patients with history of stroke (1B recommendation) or history of malignancy (2C recommendation) 2
• Her hemoglobin of 8.16 g/dL is below 10 g/dL, which would typically trigger ESA consideration in CKD, but her stroke history is an absolute contraindication 2, 5
• If ESA therapy were ever considered after IV iron failure, target hemoglobin should never exceed 11 g/dL due to increased risks of death, cardiovascular events, and stroke recurrence 2, 5
• The FDA label for epoetin alfa specifically warns against targeting hemoglobin >11 g/dL in CKD patients due to increased mortality and cardiovascular risks 5

Cardiovascular Medication Optimization

Continue her current heart failure medications (likely including ACE inhibitor/ARB and potentially SGLT2 inhibitor) as these provide mortality benefit despite renal impairment. 2, 1

• ACE inhibitors or ARBs should be continued unless creatinine exceeds 2.5 mg/dL (her creatinine is 1.8) or potassium exceeds 5.5 mmol/L 1
• Small creatinine increases (up to 30%) after ACE inhibitor initiation are acceptable and associated with long-term benefit 2, 1
• SGLT2 inhibitors can be initiated at GFR as low as 20 mL/min/1.73m² and reduce cardiovascular and kidney disease progression 2
• Beta-blockers should be optimized for additional mortality benefit in HFpEF 1
• Consider mineralocorticoid receptor antagonist (MRA) if potassium <5.0 mmol/L, as this reduces heart failure hospitalizations 2

Monitoring Strategy

Recheck laboratory parameters within 7-10 days to ensure stability and avoid medication discontinuation from transient changes. 1

• Monitor creatinine, BUN, potassium, and sodium to detect hyperkalemia or acute kidney injury 1
• Potassium should be rechecked within 4-6 days given her age and renal impairment 1
• Hemoglobin should be monitored weekly initially after IV iron, then monthly once stable 2, 5
• Reassess iron studies (ferritin, transferrin saturation) 2 months after completing IV iron course 2, 1
• Monitor for volume overload with clinical examination and consider NT-proBNP or BNP levels 2, 1

Diuretic Management

Optimize loop diuretic dosing based on volume status, as thiazides are ineffective at her GFR level. 1

• Loop diuretics require higher doses when GFR <30-40 mL/min due to impaired tubular secretion 1
• Thiazide diuretics should be avoided in elderly patients with GFR <40 mL/min as they are ineffective 1
• Adjust diuretic dose based on clinical signs of congestion (edema, orthopnea, elevated jugular venous pressure) 1

Additional Investigations Required

Evaluate for occult gastrointestinal blood loss given her history of esophageal cancer, GERD, and potential antiplatelet/anticoagulant use. 3

• Iron deficiency in elderly patients requires thorough GI investigation to exclude malignancy, particularly with cancer history 3
• Consider fecal occult blood testing and potentially endoscopy if clinically appropriate 3
• Review all medications for antiplatelet agents (aspirin) or anticoagulants that increase GI bleeding risk 3
• Her hypoalbuminemia (2.9) may indicate malnutrition, malabsorption, or protein-losing enteropathy requiring further evaluation 3

Critical Pitfalls to Avoid

Do not discontinue ACE inhibitors or SGLT2 inhibitors for modest creatinine increases during appropriate volume management. 2, 1

• Creatinine increases up to 30% are acceptable and reversible with ACE inhibitors, particularly during decongestion 2, 1
• Premature discontinuation of these mortality-reducing medications worsens long-term outcomes 1

Do not prescribe oral iron as first-line therapy in this patient with heart failure and CKD. 1

• Oral iron is poorly absorbed and ineffective in chronic inflammatory states 3, 1
• IV iron is superior for symptom improvement and functional capacity in heart failure 1

Do not initiate ESA therapy given her stroke history and cancer history, which are strong contraindications. 2, 5

Do not target hemoglobin >11 g/dL if ESA therapy is ever considered, as this increases mortality and cardiovascular events. 2, 5

Do not use thiazide diuretics at her GFR level, as they are ineffective when GFR <40 mL/min. 1

Expected Response and Follow-up

After IV iron therapy, expect hemoglobin to increase by 1-2 g/dL over 2 months if iron deficiency was contributing. 2

• If hemoglobin fails to increase by >1 g/dL after 2-3 months of IV iron, consider other causes: chronic inflammation from her multiple comorbidities, inadequate erythropoietin production from CKD, or ongoing blood loss 2, 3
• If hemoglobin remains <9 g/dL despite IV iron and she develops symptomatic anemia (fatigue, dyspnea, angina), blood transfusion may be necessary rather than ESA therapy given her contraindications 2, 5
• Continue monitoring renal function monthly, as progressive CKD will worsen anemia and may eventually require more aggressive management 2, 4