Abstract
Background: Patients with chronic kidney disease (CKD) are at very high cardiovascular risk, with heart failure and anemia being two common conditions that significantly affect prognosis. Anemia in CKD is often attributed to decreased erythropoietin production and disordered iron metabolism; however, vitamin B12 deficiency is a potentially reversible cause that may be overlooked. Case Presentation: We report the case of an 89-year-old male patient with stage 4 chronic kidney disease, coronary artery disease, and heart failure with reduced ejection fraction, who was admitted for chest tightness and dyspnea. The patient had persistent anemia with poor response to erythropoietin and iron therapy, accompanied by macrocytosis (MCV 130-141 fL). Laboratory tests revealed vitamin B12 <148 pg/mL, while folic acid levels were normal. After vitamin B12 supplementation, hemoglobin increased from 8.2 g/dL to 10.2 g/dL without the need for blood transfusion. The patient subsequently underwent successful coronary intervention. Conclusion: This case highlights the importance of assessing vitamin B12 levels in CKD patients with macrocytic anemia and poor response to erythropoietin, even in those not yet on maintenance dialysis. Recommendation: In patients with CKD who present with macrocytic anemia or a poor response to standard therapy, serum vitamin B12 levels should be proactively assessed, even if the patient is not yet on maintenance dialysis.
