American Board of Internal Medicine (ABIM) Certification Practice Exam

When should erythropoiesis-stimulating agents (ESAs) be considered for patients with chronic kidney disease (CKD)?

1. When hemoglobin is less than 8 g/dL

2. When hemoglobin is less than 10 g/dL

3. When hemoglobin is less than 12 g/dL

4. When hemoglobin is less than 14 g/dL

The correct answer is: When hemoglobin is less than 10 g/dL

Erythropoiesis-stimulating agents (ESAs) are recommended for patients with chronic kidney disease (CKD) when their hemoglobin level falls below 10 g/dL. The rationale for initiating ESAs at this hemoglobin threshold is to manage anemia, which is a common complication of CKD due to inadequate erythropoietin production by the kidneys. Starting treatment at a hemoglobin level lower than 10 g/dL is based on clinical studies that have shown improved quality of life and functional status in patients receiving ESAs at this level. Furthermore, it helps in reducing the need for blood transfusions, which carry risks and associated complications. On the other hand, initiating ESAs when hemoglobin levels are higher may not provide additional benefits and could increase the risk of cardiovascular events and other adverse effects. Therefore, maintaining a hemoglobin level around 10 g/dL with the use of ESAs is considered optimal for managing anemia in CKD patients.