Intravenous iron-sucrose complex to reduce epoetin demand in dialysis patients

Oral versus Intravenous Iron Supplementation in Peritoneal Dialysis Patients

The vast majority of erythropoietin (EPO)–treated peritoneal dialysis (PD) patients require iron supplementation. Most authors and clinical practice guidelines recommend primary oral iron supplementation in PD patients because it is more practical and less expensive. However, numerous studies have clearly demonstrated that oral iron therapy is unable to maintain EPO-treated PD patients in positive iron balance. Once patients become iron-deficient, intravenous iron administration has been found to more effectively augment iron stores and hematologic response than does oral therapy.

We recently performed a prospective, cross-over trial in 28 iron-replete PD patients and showed that twice-monthly outpatient iron polymaltose infusions (200 mg) were a practical and safe alternative to oral iron. That treatment produced significant increases in hemoglobin concentration and body iron stores. The additional expense of intravenous iron therapy was completely offset by reductions in EPO dosage.

Careful monitoring of iron stores is important in patients receiving intravenous iron supplementation in view of epidemiologic links with infection and cardiovascular disease. Nevertheless, a growing body of evidence suggests that, as has been found for hemodialysis patients, intravenous iron therapy is superior to oral iron supplementation in EPO-treated PD patients.

Experience with a Large Dose (500 MG) of Intravenous Iron Dextran and Iron Saccharate in Peritoneal Dialysis Patients

Objective

To compare efficacy in anemia correction and side effects of large doses of intravenous (IV) iron dextran and iron saccharate preparations in peritoneal dialysis (PD) patients.

Setting

Tertiary-care teaching hospital of University of Toronto.

Design

Retrospective analysis of 379 PD patients who attended PD clinics in past 5 years. Of these 379 patients, 62 were selected to receive IV iron based on ferrokinetic markers of iron deficiency, noncompliance to or ineffectiveness of oral iron, or increased erythropoietin (EPO) requirement.

Intervention

Sixty-one patients received two IV iron injections of 500 mg each, 1 week apart, 33 patients received iron dextran, 23 received iron saccharate, and 5 received both iron dextran and iron saccharate. One patient developed anaphylaxis to a test dose of iron dextran and was excluded from further therapy. Blood samples were collected before and 3 and 6 months after iron infusions.

Results

At 3 months, the group's average hemoglobin rose from 98.3 ± 18.3 g/L to 110.6 ± 16.4 g/L ( p < 0.0001). Ferritin rose from 104.9 ± 115.4 μg/L to 391.5 ± 294.1 μg / L ( p < 0.0001), and iron saturation from 0.17 ± 0.07 to 0.26 ± 0.19 ( p < 0.0001). Erythropoietin requirements fell from 7278.7 IU/week to 5900 IU/week ( p < 0.01). Five of the 34 patients who received iron dextran developed minor side effects and 1 patient had anaphylaxis to the test dose. Of the 23 patients who received iron saccharate, 1 had an anaphylactic reaction and 2 had transient chest pain, which subsided without therapy. Overall, there were more side effects with iron dextran (7.4% of injections) compared to the iron saccharate group (4.3% of injections), but this difference was statistically insignificant. Although statistically insignificant, there was an increase in the number of peritonitis episodes during the 6 months after IV iron infusion, especially with iron dextran, compared to the peritonitis episodes during the 6 months before iron infusions.

Conclusion

Our study indicates that IV iron in PD patients is effective in restoring iron stores and in decreasing EPO requirements. One anaphylactic reaction occurred in each group. Our data suggest that as much caution be exercised with iron saccharate as with iron dextran. The slight trend toward increased peritonitis rates after iron infusions needs to be investigated in a larger group of patients.

Efficacy of a Low-Dose Intravenous Iron Sucrose Regimen in Peritoneal Dialysis Patients

Objective

Sufficient iron substitution leads to a decrease in the required recombinant human erythropoietin (rHuEPO) dose and/or an increased hematocrit in dialysis patients. Intravenous (IV) application of larger doses of iron sucrose may be associated with hyperferritinemia, appearance of catalytically free iron, and impaired phagocyte function. Therefore, we investigated the effectiveness of a low-dose IV iron regimen in peritoneal dialysis (PD) patients.

Patients and Interventions

Forty-five PD patients were followed over a period of 1 year. Serum ferritin, serum transferrin saturation, and hemoglobin were measured monthly. In cases of absolute iron deficiency (serum ferritin < 100 μg/L), 50 mg iron sucrose was given IV every second week. In cases of functional iron deficiency (ferritin ≥ 100 μg/L and transferrin saturation < 20%) and in iron repleted patients (ferritin ≥ 100 μg/L and transferrin saturation ≥ 20%), 50 mg IV iron sucrose was applied monthly. Iron therapy was stopped in cases of acute infection (until complete recovery) and when serum ferritin level was ≥ 600 μg/L.

Results

To analyze the influence of iron substitution on erythropoiesis and rHuEPO requirements, the EPO resistance index (ERI; quotient of rHuEPO dose in units/kilogram/week and hemoglobin in grams per deciliter) was calculated every 3 months. The ERI decreased significantly during the course of the study in the whole patient group ( p = 0.009) as well as in the subgroup of 21 patients with absolute iron deficiency ( p = 0.01). A nonsignificant decrease in the ERI was observed within the group of 14 iron repleted patients ( p = 0.5). There was no significant change in the ERI in 10 patients with functional iron deficiency ( p = 0.6).

Conclusion

The low-dose IV iron regimen used in this study substantially decreased rHuEPO requirements in patients with absolute iron deficiency and was effective in maintaining iron stores in iron repleted patients. However, in the absence of significant hyperparathyroidism, aluminum toxicity, or inadequate dialysis, it did not improve the ERI in patients with functional iron deficiency.

Practical considerations for iron therapy in the management of anaemia in patients with chronic kidney disease

Clinical practice guidelines provide both local and global recommendations for the use of iron therapy in the management of anaemia in patients with chronic kidney disease. However, physicians must interpret and adapt these guidelines to meet the specific needs of their individual patients. The recommendations must also be considered in the context of findings from more recently published clinical trials and observational studies.

Heme iron polypeptide for the treatment of iron deficiency anemia in non-dialysis chronic kidney disease patients: a randomized controlled trial

Background

Anemia secondary to iron deficiency is common in patients with non-dialysis dependent chronic kidney disease (ND-CKD) but it is unclear if oral supplementation is as effective as intravenous (IV) supplementation in re-establishing iron stores. The purpose of this study was to determine if oral Heme Iron Polypeptide (HIP) is as effective as IV iron sucrose in the treatment of iron-deficiency anemia for patients with ND-CKD.

Methods

Forty ND-CKD patients were randomized; 18 to HIP 11 mg orally 3 times per day and 22 to IV iron sucrose 200 mg monthly for 6 months. Baseline clinical and laboratory data were collected for all patients. The primary and secondary outcomes for the study were hemoglobin (Hgb) concentration and iron indices [ferritin and percentage transferrin saturation (TSAT)] at the end of 6 months respectively. Adverse events were also compared.

Results

The baseline demographic characteristics and laboratory values were similar for the two groups. After 6 months of treatment, Hb in the HIP group was 117 g/L and 113 g/L in the IV sucrose group (p = 0.37). The TSAT at 6 months was not different between the two groups {p = 0.82}but the serum ferritin was significantly higher in the IV iron sucrose group {85.5 ug/L in HIP and 244 ug/L; p = 0.004}. Overall adverse events were not different between the groups.

Conclusion

HIP is similar in efficacy to IV iron sucrose in maintaining hemoglobin in ND-CKD patients with no differences in adverse events over 6 months. It is unclear if the greater ferritin values in the IV iron sucrose group are clinically significant.

Trial registration

ClinicalTrials.gov: NCT00318812

A randomized controlled trial of oral heme iron polypeptide versus oral iron supplementation for the treatment of anaemia in peritoneal dialysis patients: HEMATOCRIT trial

BACKGROUND

Preliminary clinical evidence suggests that heme iron polypeptide (HIP) might represent a promising, novel oral iron supplementation strategy in chronic kidney disease. The aim of this multi-centre randomized controlled trial was to determine the ability of HIP administration to augment iron stores in darbepoetin (DPO)-treated patients compared with conventional oral iron supplementation.

METHODS

Adult peritoneal dialysis (PD) patients treated with DPO were randomized 1:1 to receive two capsules daily of either HIP or ferrous sulphate per os for 6 months. The primary outcome measure was transferrin saturation (TSAT). Secondary outcomes comprised serum ferritin, haemoglobin, DPO dose and responsiveness, and adverse events.

RESULTS

Sixty-two patients were randomized to HIP (n = 32) or ferrous sulphate (n = 30). On intention-to-treat analysis, the median (inter-quartile range) TSAT was 22% (16-29) in the HIP group compared with 20% (17-26) in controls (P = 0.65). HIP treatment was not significantly associated with TSAT at 6 months on multivariable analysis (P = 0.95). Similar results were found on per-protocol analysis and subgroup analysis in iron-deficient patients. Serum ferritin levels at 6 months were significantly lower in the HIP group (P = 0.003), while the cost of HIP was 7-fold higher than that of ferrous sulphate. No other differences in secondary outcomes were observed.

CONCLUSIONS

HIP showed no clear safety or efficacy benefit in PD patients compared with conventional oral iron supplements. The reduction in serum ferritin levels and high costs associated with HIP therapy suggest that this agent is unlikely to have a significant role in iron supplementation in PD patients.

Integrated Care of Anemia in Chronic Kidney Disease Patients: Concepts in Intravenous Iron Management: Part One

Chronic kidney disease (CKD) has become a worldwide public health issue with increasing prevalence in the United States. As kidney function declines, anemia or other complications may arise, and hemodialysis (HD) or kidney transplantation may be needed. Early intervention and treatment of CKD complications will improve clinical outcomes and may delay or prevent disease sequelae. Primary or adjuvant iron replacement in CKD patients with anemia is recommended. The National Kidney Foundation guidelines state that patients receiving erythropoiesis-stimulating agent (ESA) therapy and HD will require intravenous (IV) iron for optimal iron stores and ESA efficacy. This article, the first of a two-part series, details the optimization of IV iron therapy in CKD patients, clinical trial evaluation of IV versus oral iron in the non–HD-dependent CKD patient, and a comparison of the four available IV iron agents. The percent changes in ESA utilization in conjunction with iron therapy and the associated cost savings are also addressed. The second article in this series goes on to describe elements of the medication use process for care of CKD patients with anemia.

Can intravenous iron therapy meet the unmet needs created by the new restrictions on erythropoietic stimulating agents?

In 2008, after reports of an association between erythropoietic stimulating agent (ESA) therapy and the potential for either thrombotic cardiovascular events or more rapid tumor progression in some cancers, the Food and Drug Administration changed the product labeling for ESAs, adding a black box warning as well as more restrictive indications, especially in oncology patients. In addition the Centers for Medicare and Medicaid Services has placed significant restrictions on payments for ESA therapy. These new limitations on ESA have led to increased use of transfusions in anemic cancer patients. This increase in allogeneic transfusions potentially will place an additional burden on the US blood supply. Although allogeneic blood transfusion is one answer to ESA restrictions, the use of intravenous iron therapy (IV iron) is another possible alternative. We will discuss the use of IV iron as primary therapy for anemia, the use of combination IV iron and ESA therapy to improve efficiency and decrease costs, and evidence that IV iron with and without ESA therapy can reduce allogeneic blood transfusions in surgical patients. We will also review the available IV iron agents and their comparative safety profiles.

Rationale and design of the oral HEMe iron polypeptide Against Treatment with Oral Controlled Release Iron Tablets trial for the correction of anaemia in peritoneal dialysis patients (HEMATOCRIT trial)

Background

The main hypothesis of this study is that oral heme iron polypeptide (HIP; Proferrin^® ES) administration will more effectively augment iron stores in erythropoietic stimulatory agent (ESA)-treated peritoneal dialysis (PD) patients than conventional oral iron supplementation (Ferrogradumet^®).

Methods

Inclusion criteria are peritoneal dialysis patients treated with darbepoietin alpha (DPO; Aranesp^®, Amgen) for ≥ 1 month. Patients will be randomized 1:1 to receive either slow-release ferrous sulphate (1 tablet twice daily; control) or HIP (1 tablet twice daily) for a period of 6 months. The study will follow an open-label design but outcome assessors will be blinded to study treatment. During the 6-month study period, haemoglobin levels will be measured monthly and iron studies (including transferring saturation [TSAT] measurements) will be performed bi-monthly. The primary outcome measure will be the difference in TSAT levels between the 2 groups at the end of the 6 month study period, adjusted for baseline values using analysis of covariance (ANCOVA). Secondary outcome measures will include serum ferritin concentration, haemoglobin level, DPO dosage, Key's index (DPO dosage divided by haemoglobin concentration), and occurrence of adverse events (especially gastrointestinal adverse events).

Discussion

This investigator-initiated multicentre study has been designed to provide evidence to help nephrologists and their peritoneal dialysis patients determine whether HIP administration more effectively augments iron stores in ESP-treated PD patients than conventional oral iron supplementation.

Trial Registration

Australia New Zealand Clinical Trials Registry number ACTRN12609000432213.

Intravenous versus Oral Iron Supplementation in Peritoneal Dialysis Patients

Iron supplementation is required in a preponderance of peritoneal dialysis (PD) patients treated with erythropoietic stimulatory agents (ESAs). Although many authors and clinical practice guidelines recommend primary oral iron supplementation in ESA-treated PD patients, numerous studies have clearly demonstrated that, because of a combination of poor bioavailability of oral iron, gastrointestinal intolerance, and noncompliance, oral iron supplementation is insufficient for maintaining a positive iron balance in these patients over time. Controlled trials have demonstrated that, in iron-deficient and iron-replete PD patients alike, intravenous (IV) iron supplementation results in superior iron stores and hemoglobin levels with fewer side effects than oral iron produces. Careful monitoring of iron stores in patients receiving IV iron supplementation is important in view of conflicting epidemiologic links between IV iron loading and infection and cardiovascular disease. Emerging new iron therapies such as heme iron polypeptide and ferumoxytol may further enhance the tolerability, efficacy, and ease of administration of iron in PD patients.

Hepatocellular Damage Following Therapeutic Intravenous Iron Sucrose Infusion in a Child

The maximum tolerated single dose of intravenous iron infusion and iron pharmacokinetics are not known in children and not clear in adults. The case reported here is of a child given a large dose of intravenous iron sucrose (16 mg/kg) over 3 hours, who subsequently developed features of systemic iron toxicity. A TDM consultant discusses the case in the context of toxicokinetic analysis. Because the maximum tolerated dose and pharmacokinetics of intravenous iron preparations are not known, their use in both adults and children should still be undertaken with caution.

Oxidative stress from rapid versus slow intravenous iron replacement in haemodialysis patients

METHODS AND RESULTS

Oxidative stress was examined in 19 erythropoietin-treated haemodialysis patients who were receiving 100 mg of iron sucrose every 2 weeks by two intravenous methods, rapid injection and slow infusion. There were no significant differences in incidence of iron oversaturation state between the two methods. Regarding oxidative stress markers, the values of plasma and red blood cell thiobarbituric acid reactive substances (TBARS) expressed in terms of malonyldialdehyde (MDA) equivalents following the two methods did not increase, and the values of area under the curve (AUC) of both markers were not different between both regimens. Also, there were no significant differences in the values of plasma and AUC of anti-oxidant markers including total anti-oxidant status, reduced thiols, and vitamin E among both periods treated with two intravenous iron methods.

CONCLUSION

As such, both intravenous iron methods could be safely used without enhancing oxidative stress in haemodialysis patients. The rapid injection method would be the preferred method of intravenous iron administration because it is more convenient while still retaining the safety profile.

Postoperative intravenous iron used alone or in combination with low-dose erythropoietin is not effective for correction of anemia after cardiac surgery

OBJECTIVES

The aim of this study was to examine whether intravenous iron III-hydroxide sucrose complex (IHSC) used alone was sufficient to provide rapid correction of anemia after cardiac surgery and whether additional stimulation of erythropoiesis is possible by means of a single low dose of recombinant-human erythropoietin (r-HuEPO) administration.

DESIGN

Prospective, randomized, double-blind study.

SETTING

The study was conducted in a university hospital.

PARTICIPANTS

One hundred twenty American Society of Anesthesiologists II or III patients, who underwent elective cardiac surgery using cardiopulmonary bypass and in whom postpump hemoglobin ranged between 7 and 10 g/dL.

INTERVENTIONS

Patients were divided into 3 groups: group I = control; group II received postoperative intravenous iron supplementation with an iron III-hydroxide sucrose complex (IHSC); and group III received IV iron and a single dose of r-HuEPO (300 U/kg).

MEASUREMENTS AND RESULTS

No significant difference in transfusion needs was observed among the 3 groups (22%, 25%, and 17% of patients transfused in groups I, II, and III, respectively). Hemoglobin levels, reticulocyte counts, and serum ferritin levels were evaluated at different time intervals (until day 30 postoperatively). No side effects because of iron administration were noted in the study. Reticulocyte counts increased rapidly at day 5 (2.24% +/- 1.11%, 1.99% +/- 1.44%, and 3.84% +/- 2.02% in groups I, II, and III, respectively) and decreased after day 15 in the 3 groups. Ferritin levels increased significantly at day 5 in the 2 treated groups (899.33 +/- 321.55 ng/mL in group II, 845.75 +/- 289.96 ng/mL in group III v 463.15 +/- 227.74 ng/mL in group I). In group I, ferritin levels, after a slight elevation on day 5, decreased at day 15 to lower than baseline levels. No significant difference in hemoglobin increase was noted among the 3 groups.

CONCLUSION

Postoperative intravenous iron supplementation alone or in combination with a single dose of r-HuEPO (300 U/kg) is not effective in correcting anemia after cardiac surgery.

Iron sucrose: the oldest iron therapy becomes new

Several parenteral iron preparations are now available. This article focuses on iron sucrose, a hematinic, used more widely than any other for more than five decades, chiefly in Europe and now available in North America. Iron sucrose has an average molecular weight of 34 to 60 kd, and after intravenous (IV) administration, it distributes into a volume equal to that of plasma, with a terminal half-life of 5 to 6 hours. Transferrin and ferritin levels can be measured reliably 48 hours after IV administration of this agent. Iron sucrose carries no "black-box" warning, and a test dose is not required before it is administered. Doses of 100 mg can be administered over several minutes, and larger doses up to 300 mg can be administered within 60 minutes. The efficacy of iron sucrose has been shown in patients with chronic kidney disease (CKD) both before and after the initiation of dialysis therapy. Iron sucrose, like iron gluconate, has been associated with a markedly lower incidence of life-threatening anaphylactoid reactions and may be administered safely to those with previously documented intolerance to iron dextran or iron gluconate. Nonanaphylactoid reactions, including non-life-threatening hypotension, nausea, and exanthema, also are extremely uncommon with iron sucrose. Management of patients with the anemia of CKD mandates that we carefully examine the effectiveness and safety of this oldest of iron preparations and the accumulating present-day data regarding it and contemporaneous agents.

Considerations for optimal iron use for anemia due to chronic kidney disease

BACKGROUND

Availability of recombinant human erythropoietin (rHuEPO) has improved the treatment of anemia due to chronic kidney disease (CKD). Iron deficiency is the most common cause of resistance to rHuEPO therapy, contributing to ineffective erythropoiesis and hematocrit/hemoglobin values below the recommended target range (33%-36%/11-12 g/dL). I.v. iron supplementation is necessary to meet increased iron demands from stimulation of erythropoiesis and chronic blood loss; however, questions remain as to the optimal supplementation strategy to maintain appropriate yet safe iron status. Treatment guidelines for anemia management have been developed through the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI).

OBJECTIVE

This review presents the basis of need for the NKF-K/DOQI guidelines and includes detailed information concerning iron physiology, metabolism, iron preparations, and evaluation of iron status.

METHODS

This review was based on a MEDLINE search and complemented by references from the NKF-K/DOQI guidelines (whose review extended beyond MEDLINE). References focusing on normal iron physiology and metabolism, alterations in iron physiology in patients with CKD, laboratory evaluation methods, and strategies for iron supplementation were obtained from MEDLINE and reviewed for content.

RESULTS

Controversy over appropriate use of iron supplementation has led to disparity in accepted practice procedures. Oral iron (ferrous salts and polysaccharide iron complex) and i.v. iron preparations (iron dextran, sodium ferric gluconate, and iron sucrose) are available. Problems with oral iron supplementation include limited absorption and patient noncompliance. Although most available data on i.v. iron use in the United States are specific to iron dextran preparations, published information based on clinical use of sodium ferric gluconate and iron sucrose products has been promising. The use of chronic i.v. iron administration to sustain iron stores has been more widely accepted to prevent development of absolute and functional iron deficiency.

CONCLUSIONS

Although iron therapy is commonly warranted in patients with CKD, questions remain as to the most favorable supplementation strategy to optimize therapy through improvements in hematocrits, efficient use of rHuEPO, and maintenance of appropriate and safe iron levels. Clinicians will need to devise strategies based on the compilation of information from clinical experience and the available literature. Clinical practice guidelines devised by the NKF-K/DOQI have provided a useful tool for the medical community using both these resources.

A prospective crossover trial comparing intermittent intravenous and continuous oral iron supplements in peritoneal dialysis patients

BACKGROUND

Concomitant iron supplementation is required in the great majority of erythropoietin (Epo)-treated patients with end-stage renal failure. Intravenous (i.v.) iron supplementation has been demonstrated to be superior to oral iron therapy in Epo-treated haemodialysis patients, but comparative data in iron-replete peritoneal dialysis (PD) patients are lacking.

METHODS

A 12-month, prospective, crossover trial comparing oral and i.v. iron supplementation was conducted in all Princess Alexandra Hospital PD patients who were on a stable dose of Epo, had no identifiable cause of impaired haemopoiesis other than uraemia, and had normal iron stores (transferrin saturation >20% and serum ferritin 100-500 mg/l). Patients received daily oral iron supplements (210 mg elemental iron per day) for 4 months followed by intermittent, outpatient i.v. iron infusions (200 mg every 2 months) for 4 months, followed by a further 4 months of oral iron. Haemoglobin levels and body iron stores were measured monthly.

RESULTS

Twenty-eight individuals were entered into the study and 16 patients completed 12 months of follow-up. Using repeated-measures analysis of variance, haemoglobin concentrations increased significantly during the i.v. phase (108+/-3 to 114+/-3 g/l) compared with each of the oral phases (109+/-3 to 108+/-3 g/l and 114+/-3 to 107+/-4 g/l, P<0.05). Similar patterns were seen for both percentage transferrin saturation (23.8+/-2.3 to 30.8+/-3.0%, 24.8+/-2.1 to 23.8+/-2.3%, and 30.8+/-3.0 to 26.8+/-2.1%, respectively, P<0.05) and ferritin (385+/-47 to 544+/-103 mg/l, 317+/-46 to 385+/-47 mg/l, 544+/-103 to 463+/-50 mg/l, respectively, P=0.10). No significant changes in Epo dosages were observed throughout the study. I.v. iron supplementation was associated with a much lower incidence of gastrointestinal disturbances (11 vs 46%, P<0.05), but exceeded the cost of oral iron treatment by 6.5-fold.

CONCLUSIONS

Two-monthly i.v. iron infusions represent a practical alternative to oral iron and can be safely administered to PD patients in an outpatient setting. Compared with daily oral therapy, 2-monthly i.v. iron supplementation in PD patients was better tolerated and resulted in superior haemoglobin levels and body iron stores.

Optimizing erythropoietin therapy in hemodialysis patients

The European Best Practice Guidelines for the management of anemia in patients with chronic renal failure recommend the percentage of hypochromic red blood cells (%HRCs) as the best measure of iron use by erythropoietic tissues. They suggest that "sufficient iron should be administered to attain: serum ferritin 100 ng/mL, HRCs <10%. In practice, to achieve these minimum criteria will mean aiming for optimal levels of serum ferritin 200-500 ng/mL, HRCs <2.5%." We increased prospectively the delivered dose of iron supplements to a large (n = 228) unselected hemodialysis cohort with a sustained (24-month) hemoglobin (Hb) outcome meeting the UK Renal Association minimum standard of 85%, greater than or equal to 10.0 g/dL. This was managed through a computer-aided decision support system for erythropoietin (EPO) and intravenous iron sucrose therapy. Hb outcome was maintained with medians between 11.3 and 11.8 g/dL. Median red blood cell hypochromia (%HRCs) decreased from 8% (interquartile range [IQR], 3 to 15) to 4% (IQR, 2 to 8; P < 0.001, U-Mann Whitney test). Serum ferritin level increased from a median of 188 (IQR, 115 to 256) to 480 ng/mL (IQR, 397 to 595; P < 0.001, U-Mann Whitney test). Median EPO dose decreased from 136 (IQR, 83 to 216) to 72 IU/kg/wk (IQR, 33 to 134), which strongly correlated with median %HRCs through the range less than 10% (Spearman's correlation, 0.73; P < 0.01). These data suggest that EPO responsiveness continues to improve toward the normal range for %HRCs (<2.5%) and aspiring to values much less than 10% is cost-effective. The ferritin outcome required to achieve these lower values for %HRC outcome is greater than the current recommended range, although in steady state, the mean iron treatment dose is similar to that in previous studies (ie, approximately 60 mg/wk).

Iron Sucrose Injection

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The comparative safety of intravenous iron dextran, iron saccharate, and sodium ferric gluconate

Intravenous iron treatment is an important component of anemia therapy for patients on dialysis. Until recently iron dextran was the only parenteral form of iron available in the United States. This drug has been associated with occasional serious adverse reactions, including full-blown anaphylaxis. In 1999 the Food and Drug Administration approved a second form of iron for intravenous administration, sodium ferric gluconate in sucrose. It is expected that by the time of this publication, a third agent, iron saccharate will also be approved. In this review the comparative safety of these three agents is critically evaluated.

Anemia in IBD: the overlooked villain

During the past decade relevant progress has been made in the understanding and treatment of IBD-associated anemia. Effective replacement of iron deficits has become safe by using novel intravenous iron preparations such as iron sucrose. The ability of erythropoietin to interfere with key mechanisms of myelosuppression in anemia of chronic diseases also benefits patients with IBD-associated anemia. Concerns about cost effectiveness have been raised and weighed against the potential improvement in quality of life. Gastroenterologists who are caring for IBD patients should be concerned with low hemoglobin levels, since the quality of life in these patients can be as low as in anemic patients with advanced cancer. Also provided is a structured approach to cost-effective therapy.

Anemia in IBD: the overlooked villain

During the past decade relevant progress has been made in the understanding and treatment of IBD-associated anemia. Effective replacement of iron deficits has become safe by using novel intravenous iron preparations such as iron sucrose. The ability of erythropoietin to interfere with key mechanisms of myelosuppression in anemia of chronic diseases also benefits patients with IBD-associated anemia. Concerns about cost effectiveness have been raised and weighed against the potential improvement in quality of life. Gastroenterologists who are caring for IBD patients should be concerned with low hemoglobin levels, since the quality of life in these patients can be as low as in anemic patients with advanced cancer. Also provided is a structured approach to cost-effective therapy.

Parenteral iron use in the management of anemia in end-stage renal disease patients

Intravenous iron is required by most dialysis patients receiving erythropoietin (EPO) to maintain an adequate hematocrit. In the United States, there are currently two parenteral iron preparations, iron dextran and iron gluconate, approved for such use, and a third product, iron sucrose, is under development. This article reviews each of these products. Each of the iron products increases the efficacy of EPO use in anemia management. There is considerable experience in the United States and elsewhere with the use of iron dextran. Although it is clinically effective, iron dextran is also associated with significant morbidity from both dose-dependent and -independent side effects. The slow release of iron from this complex necessitates a delay in monitoring iron indices after the administration of large doses of iron dextran. Recommended doses of iron sucrose appear very safe with little risk of anaphylactic reactions. Adverse effects are uncommon and not life threatening. If approved for use in the United States, iron sucrose may be a safe and effective alternative to iron dextran. Iron dissociates from iron gluconate quite rapidly and may increase the production of ionized free iron. Iron gluconate may be a safe alternative to iron dextran for patients with severe reactions, including anaphylaxis. The risk of allergic reactions to iron gluconate is very low. The exact place in therapy for the newer iron complexes remains unclear. Currently available data suggest that iron sucrose and iron gluconate may have diminished adverse effect profiles when compared with iron dextran. Additional clinical experience will establish the role for these new iron products.

Strategies for iron supplementation: oral versus intravenous

Iron supplementation has become an integral part of the management of patients receiving epoetin therapy, and clinicians have found it necessary to learn how and when to use it to the best advantage. Three routes of administration for iron are available: oral, intramuscular, and intravenous. Oral iron has the advantage of being simple and cheap, but it is limited by side-effects, poor compliance, poor absorption, and low efficacy. Intravenous iron is the best means of guaranteeing delivery of readily available iron to the bone marrow, but it requires greater clinical supervision. The i.v. iron preparations vary widely in their degradation kinetics, bioavailability, side-effect profiles, and maximum dose for single administration. Iron dextran is hampered by a small but significant risk of anaphylaxis, whereas all i.v. iron preparations can induce "free iron" reactions if the circulating plasma transferrin is overloaded. Intravenous iron may be given in advance of epoetin therapy, as concomitant treatment to prevent the development of iron deficiency, as treatment of absolute or functional iron deficiency, or as adjuvant therapy to enhance the response to epoetin in iron-replete patients. Markers of iron status that may indicate a need for i.v. iron include a serum ferritin of less than 100 microg/liter, a transferrin saturation of less than 20%, and a percentage of hypochromic red cells more than 10%. Various regimens are available for giving i.v. iron: low-dose administration of 20 to 60 mg every dialysis session in hemodialysis patients, medium-dose administration of 100 to 400 mg, and high-dose administration of 500 to 1000 mg. Iron sodium gluconate can only be given as a low-dose regimen because of toxicity, whereas the only preparation suitable for high-dose administration is iron dextran. Although concerns have been raised regarding iron overload and long-term toxicity with i.v. iron therapy in terms of increased risk of infections, cardiovascular disease, and malignancy, there is little evidence to substantiate this in patients receiving epoetin. Care should be taken, however, to prevent the serum ferritin rising above 800 to 1000 microg/liter and the transferrin saturation above 50%. Provided this is done, the benefits of i.v. iron almost certainly outweigh the risks in terms of optimizing the response to epoetin therapy.

Iron status and iron supplementation in peritoneal dialysis patients

Iron deficiency represents an important problem in peritoneal dialysis patients, especially during erythropoietin therapy. A combination of serum ferritin, transferrin saturation, and/or the percentage of hypochromic red cells should be used to assess iron status in peritoneal dialysis patients. Primarily, oral iron supplementation should be the preferred therapy. However, most of the studies using oral substitution in erythropoietin-treated peritoneal dialysis patients show a progressive decline of serum ferritin. Therefore, parenteral iron supplementation is required in part of the patients, and the intravenous route should be preferred in these cases. Intravenous iron therapy is recommended if serum ferritin falls below 100 microg/liter and should be stopped if the serum ferritin level is more than 650 microg/liter. The optimal form of intravenous iron supplementation is still unclear. Injections once to three times per week restrict the patients' flexibility, but application of higher doses in longer intervals may lead to an impairment of neutrophil functions, probably connected to a higher risk of infection. We treated 17 stable peritoneal dialysis patients with 100 or 200 mg iron saccharate monthly over a period of six months and found an increase of transferrin saturation (from 12.1+/-1.6 to 20.9+/-2.4%, P = 0.026), serum ferritin (from 100.4+/-32.0 to 372.4+/-54.6 microg/liter, NS) and hematocrit (from 32.0+/-0.8% to 35.1+/-0.9%, P = 0.099). The required erythropoietin dosage could be reduced significantly (from 148.4+/-30.3 to 69.4+/-19.5 U/kg/week, P = 0.025). Side effects occurred in 0.9% after application of 100 mg and in 5.9% after injection of 200 mg iron saccharate. The incidence of catheter infections and peritonitis was the same in the period before and after the start of treatment. Further studies are needed to find the most suitable regime of iron supplementation for peritoneal dialysis patients.

Effective utilization of erythropoietin with intravenous iron therapy

INTRODUCTION

Iron replacement therapy reduces the demand for erythropoietin (EPO) in some dialysis patients. It has been postulated that iron supply to the bone marrow is a rate-limiting step in the process of erythropoiesis under erythropoietin stimulation.

METHODS

We evaluated the economic benefit of intravenous iron therapy for this purpose in a prospective, non-blinded study of 22 haemodialysis patients, 16 male, six female, mean age 62 years (range 24-80 years). All patients had a serum ferritin (SF) of < or = 60 microg/L, despite oral iron therapy. Patients with high aluminium and/or parathyroid hormone (PTH) levels, underlying bleeding/haematological disorders or active inflammatory diseases were excluded. Patients were established on subcutaneous EPO and given intravenous iron over seven consecutive dialysis sessions (total dose 1050 mg) and supplemental monthly doses with regular monitoring for 4 months.

RESULTS

The median EPO dose was 4000 units/week (mean 6050 units/week) pre-treatment and 2000 units/week (mean 3700 units) at 6 weeks post intravenous iron therapy (P=0.03). No serious adverse events occurred in the 154 treatment sessions of intravenous iron. Mean haemoglobin (Hb) level remained constant at 6 and 12 weeks (P=0.087). Serum ferritin levels (P< 0.0001) rose significantly, while a reduction in transferrin saturation (TS) became significant at the end of the study (P=0.0047). The use of intravenous iron allowed a substantial monthly cost saving per patient in our unit.

CONCLUSION

Intravenous iron therapy is a safe and cost-effective method for maintaining or improving Hb levels with a more effective utilization of EPO in patients with low SF levels despite oral iron therapy.

Use of dietetic-specific nutritional diagnostic codes in clinical reasoning relevant to the nutritional management of core clinical outcome indicators in hemodialysis patients

The Health Care Financing Agency (HCFA) has recommended conscientious monitoring of four core outcome indicators (anemia, albumin, treatment adequacy, and hypertension) by the end stage renal disease (ESRD) health care team. Dietetic-specific nutritional diagnostic categories (D-S NDCs) can be a powerful tool in guiding renal nutrition specialists through the clinical reasoning required to diagnose and clinically correct nutrition-related problems in hemodialysis (HD) patients. The purpose of this article is to portray one clinician's dual use of D-S NDCs to identify the nutritional problem responsible for poor performance and determine nutritionally treatable causes. Although four indicator-specific sets of D-S NDCs commonly used in the nutritional assessment of anemia, albumin, treatment adequacy and hypertension were identified and referenced, seven codes were consistently repeated. These D-S NDCs were (1) altered nutritional biochemistry integrity; (2) absence of/limited nutritional service; (3) deficit in nutrition knowledge; (4) imbalance of nutrient/fluid; (5) nutrition misinformation; (6) toxicity of nutrient/nutrient end-product; and (7) possibility of developing a specific disease. Thus, in ESRD, use of D-S NDCs shows the implicit role of the registered dietitian in disease prevention, management of altered nutrient disposition, and patient education.