A 54-Year-Old Woman with End-Stage Renal Disease Secondary to Diabetic

question 729

Multiple Choice

A 54-year-old woman with end-stage renal disease secondary to diabetic nephropathy and hypertension comes to the office due to easy fatigability and tiredness.  The patient experienced similar symptoms 6 months ago, but they improved after starting erythropoietin therapy for anemia.  Over the past several weeks, the symptoms have recurred but she has had no chest pain, dyspnea, palpitations, syncope, melena, or hematochezia.  The patient receives 3-4 hours of maintenance hemodialysis 3 times a week.  She has no drug allergies.
Blood pressure is 130/78 mm Hg and pulse is 70/min with no orthostatic changes.  She weighs 68 kg (150 lbs) , which is her 'dry weight'.  There are no heart murmurs.  Abdominal examination shows no organomegaly and stool occult blood testing is negative.
Laboratory studies are as follows:

Hemoglobin was 8.2 g/dL and 10.1 g/dL 6 months and 4 months ago, respectively.
Which of the following is the most appropriate next step in management of this patient's anemia?

• A)Begin intravenous iron therapy
• B)Check anti-erythropoietin antibody level
• C)Intensify dialysis treatments
• D)Perform bone marrow biopsy
• E)Transfuse packed red blood cells

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