What is the recommended treatment for a patient with iron‑deficiency anemia (low mean corpuscular hemoglobin, high red cell distribution width), vitamin D deficiency, severe dyslipidemia (total cholesterol 313 mg/dL, LDL 202 mg/dL, triglycerides 334 mg/dL) and early chronic kidney disease (estimated glomerular filtration rate ≈70 mL/min) with normal urinalysis?

Management of Iron Deficiency Anemia with CKD, Dyslipidemia, and Vitamin D Deficiency

This patient requires immediate GI evaluation (upper endoscopy and colonoscopy) to exclude GI bleeding as the source of iron deficiency, followed by intravenous iron therapy rather than oral supplementation, aggressive statin therapy for severe dyslipidemia, and vitamin D replacement. 1, 2

Iron Deficiency Anemia with CKD (GFR 70)

Immediate Diagnostic Workup Required

You must obtain serum ferritin and transferrin saturation (TSAT) immediately to properly assess iron deficiency in the context of CKD, as standard thresholds do not apply here. 1 In CKD patients, absolute iron deficiency is defined as TSAT ≤20% with ferritin ≤100 μg/L (for predialysis patients like yours with GFR 70). 1, 3

GI Investigation is Mandatory

The majority of CKD patients with confirmed iron deficiency anemia warrant GI investigation to exclude treatable causes of blood loss, particularly given the high prevalence of dual unrelated pathology and malignancy. 1 The decision should ideally involve nephrology consultation, but do not delay endoscopic evaluation if the patient is fit for procedures. 1, 3

• Perform both upper endoscopy and colonoscopy to evaluate for GI bleeding sources, as CKD patients frequently have coexisting GI pathology despite renal contribution to anemia. 1, 3
• The concern for GI bleeding you noted is appropriate and must be investigated before attributing anemia solely to CKD. 3

Iron Replacement Strategy

Oral iron supplementation (including dietary changes alone) is insufficient for this patient. 2, 4 While oral iron may be tried in predialysis CKD patients, intravenous iron is superior and should be initiated if oral iron is not tolerated or ineffective. 1

• Administer IV iron 750 mg in two doses separated by at least 7 days (total 1,500 mg per course) for patients ≥50 kg. 5
• Alternative dosing: 15 mg/kg up to maximum 1,000 mg as a single dose is also FDA-approved. 5
• Target TSAT >20% (ideally >30%) and ferritin 100-500 ng/mL. 2
• Recheck hemoglobin and iron parameters 2 weeks after completing the iron course, expecting hemoglobin increase of approximately 2 g/dL within 3-4 weeks. 2

Critical Medication Review

Immediately review and discontinue NSAIDs (which you correctly noted to avoid given GFR 70), as well as any antiplatelet agents or anticoagulants that may contribute to GI blood loss. 3 Consider proton pump inhibitor if continuing any high-risk medications. 3

Additional Anemia Workup

Before attributing anemia solely to iron deficiency and CKD, screen for hypothyroidism (TSH—already done and normal), vitamin B12, folate deficiency, hemolysis markers, and consider plasma cell dyscrasias if anemia persists despite iron repletion. 3, 6

Severe Dyslipidemia Management

This patient requires high-intensity statin therapy immediately given total cholesterol 313 mg/dL, LDL 202 mg/dL, and triglycerides 334 mg/dL, which confer extremely high cardiovascular risk.

• Initiate atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily as first-line therapy.
• Target LDL <70 mg/dL (ideally <55 mg/dL given likely cardiovascular risk factors).
• The elevated triglycerides (334 mg/dL) require additional attention: optimize glycemic control (A1C 5.5% is excellent, continue current management), address lifestyle factors (weight loss if overweight, reduce refined carbohydrates and alcohol), and consider adding icosapent ethyl 2 grams twice daily if triglycerides remain >150 mg/dL despite statin therapy.
• Recheck lipid panel in 4-6 weeks after statin initiation to assess response and adjust therapy.

CKD Considerations for Statin Use

Statins are safe and beneficial in CKD with GFR 70, though you should monitor for muscle symptoms and avoid fibrates given renal impairment unless triglycerides remain severely elevated (>500 mg/dL) despite other interventions.

Vitamin D Deficiency

Prescribe ergocalciferol (vitamin D2) 50,000 IU weekly for 8-12 weeks, then transition to maintenance dosing of 1,000-2,000 IU daily.

• Recheck 25-OH vitamin D level after 3 months to ensure repletion (target >30 ng/mL).
• In CKD, vitamin D deficiency may contribute to secondary hyperparathyroidism, so consider checking intact PTH and calcium/phosphorus levels if not recently done.

Monitoring Plan

Schedule follow-up in 1 month (as you appropriately planned) to:

• Review GI evaluation results
• Assess response to IV iron (recheck CBC with ferritin and TSAT)
• Evaluate statin tolerance and lipid response
• Confirm vitamin D repletion is underway
• Monitor renal function (repeat basic metabolic panel)

Common Pitfalls to Avoid

• Do not rely on dietary iron alone or oral iron supplementation as primary therapy in CKD—IV iron is far more effective. 2, 4
• Do not delay GI evaluation while empirically treating with iron, as this may miss treatable malignancy. 1, 3
• Do not use ferritin alone to assess iron status in CKD—you must have TSAT as well. 3, 7
• Do not underdose statins given the severity of dyslipidemia—this patient needs high-intensity therapy, not moderate-intensity.
• Avoid repeat IV iron within 3 months without checking serum phosphate, as hypophosphatemia is a recognized complication. 5