Low-Dose Maintenance Intravenous Iron Therapy Can Prevent Anemia in Children with End-Stage Renal Disease Undergoing Chronic Hemodialysis

Abstract

Iron deficiency anemia is common in children with end-stage renal disease (ESRD) on long-term hemodialysis receiving erythropoiesis-stimulating agents. One approach to maintain the iron profile and hemoglobin levels is maintenance therapy with regular low doses of intravenous (IV) iron after initial iron repletion therapy; however, evidence for the benefits of this approach is lacking. This study evaluated the effect of IV iron maintenance therapy on anemia in children on regular hemodialysis. This retrospective cohort study included 41 pediatric ESRD patients with normal hemoglobin and iron status who underwent regular hemodialysis at the Pediatric Dialysis Unit of Cipto Mangunkusumo Hospital, Indonesia, between January 2015 and April 2019. Among these, 21 received IV iron maintenance therapy with two doses of 2 mg/kg of IV iron sucrose every 2 weeks (the treatment group) and 20 did not (the comparison group). Changes in hemoglobin and transferrin saturation were assessed after 6 weeks of observation and compared between the two groups. There was a significant reduction in the mean hemoglobin level compared with the baseline level in the comparison group (21 g/L; 95% CI, 9.3–33 g/L; p=0.001) but not in the treatment group (0.7 g/L; 95% CI, −6.6–8 g/L; p=0.84). The risk of anemia was lower in the treatment group (relative risk = 0.42; 95% CI, 0.22–0.79; p=0.003). Although majority of the patients had high baseline ferritin level, this study indicates that in our setting, ferritin may not be a reliable parameter to review the iron status, as it can be affected by chronic inflammation. Hence, the decision to start IV iron maintenance therapy in patients with hyperferritinemia should consider the patient’s clinical condition and morbidity. To conclude, the coadministration of IV iron maintenance therapy is beneficial for maintaining hemoglobin levels and preventing anemia in children with ESRD who are undergoing regular hemodialysis, have achieved the target hemoglobin levels, and have normal iron status.

Experience of the first 6 years of pediatric kidney transplantation in Indonesia: A multicenter retrospective study

“…The incidence of pediatric ESRD in Indonesia is unknown at present, but data from the Indonesian Pediatrics Association indicate that 212 children with kidney failure underwent renal replacement therapy, including dialysis, in 2017 8 . A recent publication from CMH also showed that 60 pediatric cases of ESRD underwent continuous ambulatory peritoneal dialysis between 2014 and 2019, while 78 underwent chronic hemodialysis between 2015 and 2019, with kidney hypoplasia as the primary underlying disease 6,9 . However, these data likely underestimate the true prevalence of pediatric ESRD because the country has only two pediatric dialysis units located in the capital, making it extremely likely that there are many undiagnosed and untreated pediatric cases in the wider population.…”

“…Only Case 12 had a complication, presenting with a bleed adjacent to the graft that required further surgery within 3 hours after receiving the transplant ( 2019, with kidney hypoplasia as the primary underlying disease. 6,9 However, these data likely underestimate the true prevalence of pediatric ESRD because the country has only two pediatric dialysis units located in the capital, making it extremely likely that there are many undiagnosed and untreated pediatric cases in the wider population.…”

“…f Glomerular filtration rate (GFR) was calculated using the New Schwartz formula. 9 continuously for side effects. As of the last follow-up, no patient had TB reactivation in our series.…”

“…Moreover, multiple blood transfusions were given to our patients before hemodialysis and many used a hemodialysis catheter chronically and had renal cachexia, contributing to hyperferritinemia. 9 In Indonesia, HLA testing and antibody screening by solid-phase immunoassay (Luminex) are not performed routinely because of their high cost (1689 USD). As a developing country, we occasionally experience restrictions in resources that hinder the desired provision of a standardized medical service, similar to the challenge we face because of inadequate supporting laboratories.…”

<p>Successful Treatment of Hepatitis C Virus Infection Using Direct-Acting Antiviral Agents (DAAs) in Adolescents with Kidney Transplantation: A Case Series</p>

“…This situation is sometimes found in our country; as a developing country, we found constraints in resources to provide the standardized medical service. Previously, there were publications from Indonesia describing a similar challenge due to the unavailability of supporting laboratories, [20][21][22] which could require specimen transfer to laboratories outside the country and necessitated out-ofpocket expenses. As a matter of fact, the gross domestic product per capita of Indonesia in 2018 was USD $3893.60, while the cost of Harvoni© is USD $94,500 for a 12-week-treatment (in America).…”