Iron Treatment Strategies in Dialysis-Dependent CKD

Pandey, Richa; Daloul, Reem; Coyne, Daniel W.

doi:10.1016/j.semnephrol.2016.02.004

Cited by 17 publications

(13 citation statements)

References 42 publications

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“…To maintain stable iron stores in hemodialysis patients, typical monthly IV iron doses of 100 to 400 mg are required to replace ongoing losses (through blood sampling, blood loss in the hemodialysis circuit and occult gastrointestinal losses). Although no evidence-based target levels for ferritin and TSAT exist in hemodialysis patients [10, 23], periodic sampling of ferritin and TSAT is usually performed to assess iron stores and adjust iron prescriptions. When using older IV iron preparations, such as iron dextran, relatively small single doses of iron are usually given in short intervals (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…Ferritin and transferrin saturation (TSAT) are used to assess iron status in dialysis patients. Although no evidence-based targets exist [10] and recommendations differ to some extent [7, 11–14], adjustments of the dose and frequency of IV iron administration are usually based on these periodically measured laboratory values. The 2012 KDIGO guidelines on anemia management [7] recommend evaluating iron stores by measurement of ferritin and TSAT at least every three months.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing

Diebold

Kistler

2019

BMC Nephrol

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Background Iron is administered intravenously (IV) to many dialysis patients at regular intervals and iron stores are evaluated through periodic measurements of ferritin and transferrin saturation (TSAT). In patients without kidney diseases, large single doses of IV iron lead to a transient rise in serum ferritin that does not reflect iron stores. It is not known whether and to what extent smaller IV iron doses used to maintain adequate stores in hemodialysis patients lead to transient spurious elevations of ferritin and TSAT. Methods Ferritin and TSAT were serially determined over four weeks after the administration of ferric carboxymaltose (FCM) in hemodialysis patients on a stable maintenance FCM dosing regimen of 100 mg or 200 mg every four weeks. Results Ferritin values increased by 113 ± 72.2 μg/l ( P < 0.001) from baseline to the peak value and remained significantly elevated until two weeks after the administration of 100 mg FCM ( n = 19). After the administration of 200 mg FCM ( n = 12), ferritin values increased by 188.5 ± 67.56 μg/l ( P < 0.001) and remained significantly elevated by the end of week three. TSAT values increased by 12.0 ± 9.7% ( P < 0.001) and 23.1 ± 20.4% ( P = 0.002) in patients receiving 100 or 200 mg FCM, respectively, and returned to baseline within four days. Conclusions IV administration of FCM at doses of 100 or 200 mg in hemodialysis patients leads to dose-dependent transient ferritin elevations of extended duration. Temporal coordination of blood sampling for iron status evaluation with the maintenance IV iron dosing schedule is advisable. Trial registration ISRCTN12825165 (retrospectively registered 01/02/2019). Electronic supplementary material The online version of this article (10.1186/s12882-019-1263-8) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing

Diebold

Kistler

2019

BMC Nephrol

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“…To avoid potential serious adverse effects of IIT, safer regimens with low dose of IV iron have been used for the management of IDA in CKD patients. Maintenance IV iron regimen in smaller doses at frequent intervals has been more efficacious and safer than large intermittent doses [ 201 ]. Continuous low dose of IV iron sucrose was more effective in maintaining tHb compared to the regimen with bolus high dose of IV iron in HD patients [ 202 ].…”

Section: Safety Issues Of Iron Therapymentioning

confidence: 99%

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

2018

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Iron deficiency anemia (IDA) is a major problem in chronic kidney disease (CKD), causing increased mortality. Ferritin stores iron, representing iron status. Hepcidin binds to ferroportin, thereby inhibiting iron absorption/efflux. Inflammation in CKD increases ferritin and hepcidin independent of iron status, which reduce iron availability. While intravenous iron therapy (IIT) is superior to oral iron therapy (OIT) in CKD patients with inflammation, OIT is as effective as IIT in those without. Inflammation reduces predictive values of ferritin and hepcidin for iron status and responsiveness to iron therapy. Upper limit of ferritin to predict iron overload is higher in CKD patients with inflammation than in those without. However, magnetic resonance imaging studies show lower cutoff levels of serum ferritin to predict iron overload in dialysis patients with apparent inflammation than upper limit of ferritin proposed by international guidelines. Compared to CKD patients with inflammation, optimal ferritin levels for IDA are lower in those without, requiring reduced iron dose and leading to decreased mortality. The management of IDA should differ between CKD patients with and without inflammation and include minimization of inflammation. Further studies are needed to determine the impact of inflammation on ferritin, hepcidin and therapeutic strategy for IDA in CKD.

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“…In current practice, IV iron can be administered via large doses at long intervals (“load and hold”) or maintenance dosing with smaller doses at regular, shorter intervals [60, 61]. There are concerns that higher doses of IV iron could lead to temporary oversaturation of transferrin and greater concentrations of NTBI [62, 63].…”

Section: When Does Positive Iron Balance Become Iron Toxicity?mentioning

confidence: 99%

“…There are concerns that higher doses of IV iron could lead to temporary oversaturation of transferrin and greater concentrations of NTBI [62, 63]. Although large randomized controlled trials comparing different iron replacement strategies are lacking, available data suggest a more favorable risk:benefit profile with maintenance dosing in patients on HD [60]. …”

Section: When Does Positive Iron Balance Become Iron Toxicity?mentioning

confidence: 99%

Positive Iron Balance in Chronic Kidney Disease: How Much is Too Much and How to Tell?

et al. 2018

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Background: Regulation of body iron occurs at cellular, tissue, and systemic levels. In healthy individuals, iron absorption and losses are minimal, creating a virtually closed system. In the setting of chronic kidney disease and hemodialysis (HD), increased iron losses, reduced iron absorption, and limited iron availability lead to iron deficiency. Intravenous (IV) iron therapy is frequently prescribed to replace lost iron, but determining an individual’s iron balance and stores can be challenging and imprecise, contributing to uncertainty about the long-term safety of IV iron therapy. Summary: Patients on HD receiving judicious doses of IV iron are likely to be in a state of positive iron balance, yet this does not appear to confer an overt risk for clinically relevant iron toxicity. The concomitant use of iron with erythropoiesis-stimulating agents, the use of maintenance iron dosing regimens, and the reticuloendothelial distribution of hepatic iron deposition likely minimize the potential for iron toxicity in patients on HD. Key Messages: Because no single diagnostic test can, at present, accurately assess iron status and risk for toxicity, clinicians need to take an integrative approach to avoid iron doses that impose excessive exposure while ensuring sufficient replenishment of iron stores capable of overcoming hepcidin blockade and allowing for effective erythropoiesis.

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Iron Treatment Strategies in Dialysis-Dependent CKD

Cited by 17 publications

References 42 publications

Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing

Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing

Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease

Positive Iron Balance in Chronic Kidney Disease: How Much is Too Much and How to Tell?

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