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Kuo KL, Liu JS, Lin MH, Hsu CC, Tarng DC. Association of anemia and iron parameters with mortality among prevalent peritoneal dialysis patients in Taiwan: the AIM-PD study. Sci Rep 2022; 12:1269. [PMID: 35075212 PMCID: PMC8786856 DOI: 10.1038/s41598-022-05200-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022] Open
Abstract
In 1996, the National Health Insurance Administration of Taiwan applied a restrictive reimbursement criteria for erythropoiesis-stimulating agents (ESAs) use in patients with chronic kidney disease. The maximal ESAs dosage allowed by insurance is capped at 20,000 U of epoetin per month. Nephrologists avoided the use of high ESA dosages to achieve a hemoglobin level of 10–11 g/dL using iron supplementation. We assessed the association of anemia and iron parameters with mortality among peritoneal dialysis (AIM-PD) patients. A retrospective cohort study was conducted based on the Taiwan Renal Registry Data System. From January 1, 2000 to December 31, 2008, we enrolled 4356 well-nourished PD patients who were older than 20 years and had been receiving PD for more than 12 months. All patients were divided into subgroups according to different hemoglobin, ferritin and transferrin saturation (TSAT) values. Patients were followed until death or December 31, 2008. In a median 2.9-year study period, 694 (15.9%) patients died. By multivariate adjustment, a hemoglobin level lower than 10 g/dL was significantly associated with a higher risk for all-cause and cardiovascular deaths. Moreover, a serum ferritin level higher than 800 ng/mL was associated with a higher risk for all-cause deaths, and a TSAT value between 20 and 50% was associated with the lowest all-cause mortality. In conclusions, we recommend avoiding a low hemoglobin level and a serum ferritin level of more than 800 ng/mL and maintaining a TSAT value between 20 and 50%, as these conditions were associated with lower risks of all-cause mortality in the AIM-PD study.
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Affiliation(s)
- Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jia-Sin Liu
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Huang Lin
- Institute of Population Health Sciences, National Health Research Institutes, 35, Keyan Road, Zhunan Town, Miaoli County, 35053, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, 35, Keyan Road, Zhunan Town, Miaoli County, 35053, Taiwan. .,Department of Health Services Administration, China Medical University, Taichung, Taiwan. .,Department of Family Medicine, Min-Sheng General Hospital, Taoyüan, Taiwan. .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Der-Cherng Tarng
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Center for Intelligent Drug Systems and Smart Bio-Devices (IDS2B), Hsinchu, Taiwan. .,Department and Institute of Physiology, National Yang Ming Chiao Tung University, 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan. .,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
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Lee KH, Ho Y, Tarng DC. Iron Therapy in Chronic Kidney Disease: Days of Future Past. Int J Mol Sci 2021; 22:1008. [PMID: 33498292 PMCID: PMC7863960 DOI: 10.3390/ijms22031008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/10/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Anemia affects millions of patients with chronic kidney disease (CKD) and prompt iron supplementation can lead to reductions in the required dose of erythropoiesis-stimulating agents, thereby reducing medical costs. Oral and intravenous (IV) traditional iron preparations are considered far from ideal, primarily due to gastrointestinal intolerability and the potential risk of infusion reactions, respectively. Fortunately, the emergence of novel iron replacement therapies has engendered a paradigm shift in the treatment of iron deficiency anemia in patients with CKD. For example, oral ferric citrate is an efficacious and safe phosphate binder that increases iron stores to maintain hemoglobin levels. Additional benefits include reductions in fibroblast growth factor 23 levels and the activation of 1,25 dihydroxyvitamin D. The new-generation IV iron preparations ferumoxytol, iron isomaltoside 1000, and ferric carboxymaltose are characterized by a reduced risk of infusion reactions and are clinically well tolerated as a rapid high-dose infusion. In patients undergoing hemodialysis (HD), ferric pyrophosphate citrate (FPC) administered through dialysate enables the replacement of ongoing uremic and HD-related iron loss. FPC transports iron directly to transferrin, bypassing the reticuloendothelial system and avoiding iron sequestration. Moreover, this paper summarizes recent advancements of hypoxia-inducible factor prolyl hydroxylase inhibitors and future perspectives in renal anemia management.
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Affiliation(s)
- Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 11217, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDSB), Hsinchu 300, Taiwan
| | - Yang Ho
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (K.-H.L.); (Y.H.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 11217, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDSB), Hsinchu 300, Taiwan
- Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu 300, Taiwan
- Department and Institute of Physiology, National Yang-Ming University, Taipei 11217, Taiwan
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Hung PH, Yeh CC, Sung FC, Hsiao CY, Muo CH, Hung KY, Tsai KJ. Erythropoietin prevents dementia in hemodialysis patients: a nationwide population-based study. Aging (Albany NY) 2019; 11:6941-6950. [PMID: 31484803 PMCID: PMC6756878 DOI: 10.18632/aging.102227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/16/2019] [Indexed: 01/24/2023]
Abstract
Erythropoietic medications such as including erythropoietin (EPO) are known to be neuroprotective and to correlate with improved cognitive functions. However, it is not known whether supplementation with EPO reduces the risk of dementia in end-stage renal disease (ESRD) patients receiving hemodialysis (HD). Here, we determined whether EPO levels correlate with the incidence of different dementia subtypes, including Alzheimer’s disease (AD), vascular dementia (VaD), and unspecified dementia (UnD), and whether such associations vary with annual cumulatively defined daily doses (DDDs) of EPO for ESRD patients receiving HD. This retrospective study included data from 43,906 adult ESRD patients who received HD between 1999 and 2010. Using hazard ratios and Cox regression models, we found that patients receiving EPO had a 39% lower risk of general dementia than those in the non-EPO group. Similarly, the risks of VaD and UnD was lower for patients in the EPO cohort. The risk of dementia was further reduced in HD patients treated with EPO in combination with iron. Our results suggest that the use of EPO medications in HD patients is associated with a reduced risk of VaD and UnD, but not AD, regardless of whether EPO is used alone or in combination with iron.
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Affiliation(s)
- Peir-Haur Hung
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital, Chia-yi, Taiwan.,Department of Applied Life Science and Health, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chih-Ching Yeh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan.,Department of Public Health, China Medical University, Taichung, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Clinical Medical Science, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chih-Yen Hsiao
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital, Chia-yi, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu city, Taiwan
| | - Kuen-Jer Tsai
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Kuo K, Hung S, Tseng W, Tsai M, Liu J, Lin M, Hsu C, Tarng D. Association of Anemia and Iron Parameters With Mortality Among Patients Undergoing Prevalent Hemodialysis in Taiwan: The AIM - HD Study. J Am Heart Assoc 2018; 7:e009206. [PMID: 30371224 PMCID: PMC6201445 DOI: 10.1161/jaha.118.009206] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/25/2018] [Indexed: 11/16/2022]
Abstract
Background The Taiwan Health Insurance Bureau has conducted a bundled payment system for hemodialysis reimbursement since 1995. The maximum dose of erythropoiesis-stimulating agents allowed by insurance is capped at 20 000 U of epoetin or 100 μg of darbepoetin alfa per month. Nephrologists have avoided the use of high dosages of erythropoiesis-stimulating agents to achieve a hemoglobin level of 10 to 11 g/dL by iron supplementation. The clinical impact of these policies on patients' outcomes is unknown. The authors aimed to assess the AIM-HD (Association of Anemia, Iron parameters, and Mortality among the prevalent Hemodialysis patients) Study in Taiwan. Methods and Results The AIM-HD study was conducted based on the Taiwan Renal Registry Data System. From 2001 to 2008, the authors enrolled 42 230 patients undergoing hemodialysis who were older than 20 years and had received hemodialysis for more than 12 months. Patient follow-ups occurred until death or December 31, 2008. During a study period of 8 years, 12 653 (30.0%) patients died. After multivariate adjustment, the authors found that a hemoglobin level <10 g/dL was significantly associated with higher risk for all-cause and cardiovascular deaths. Moreover, a serum ferritin level between 300 and 800 ng/mL and transferrin saturation value between 30% and 50% were associated with the lowest all-cause mortality. Conclusions The authors recommend avoiding a low hemoglobin level and maintaining serum ferritin between 300 and 800 ng/mL and transferrin saturation between 30% and 50%, which were associated with lower risks of all-cause mortality among patients undergoing hemodialysis receiving the restricted erythropoiesis-stimulating agent doses but prompt intravenous iron supplementation in Taiwan.
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Affiliation(s)
- Ko‐Lin Kuo
- Division of NephrologyTaipei Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Szu‐Chun Hung
- Division of NephrologyTaipei Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Wei‐Cheng Tseng
- Division of NephrologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine and Faculty of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
| | - Ming‐Tsun Tsai
- Division of NephrologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine and Faculty of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
| | - Jia‐Sin Liu
- Department of Public HealthKaohsiung Medical UniversityKaohsiungTaiwan
| | - Ming‐Huang Lin
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
| | - Chih‐Cheng Hsu
- Institute of Clinical Medicine and Faculty of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Institute of Population Health SciencesNational Health Research InstitutesMiaoli CountyTaiwan
- Department of Health Services AdministrationChina Medical UniversityTaichungTaiwan
- Department of Family MedicineMin‐Sheng General HospitalTaoyuanTaiwan
| | - Der‐Cherng Tarng
- Division of NephrologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine and Faculty of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Department and Institute of PhysiologyNational Yang‐Ming UniversityTaipeiTaiwan
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Hung SC, Kuo KL, Tarng DC, Hsu CC, Wu MS, Huang TP. Anaemia management in patients with chronic kidney disease: Taiwan practice guidelines. Nephrology (Carlton) 2015; 19:735-9. [PMID: 25156587 DOI: 10.1111/nep.12332] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2014] [Indexed: 11/30/2022]
Abstract
The introduction of erythropoiesis-stimulating agents (ESAs) markedly improved the lives of many anaemic patients with chronic kidney disease (CKD). In Taiwan, the strategy of management of anaemia in patients with CKD was different from many other parts of the world. In 1996, the National Health Insurance Administration of Taiwan applied a more restrictive reimbursement criteria for ESA use in patients with CKD. ESA is to be initiated when non-dialysis CKD patients have a serum creatinine >6 mg/dL and a hematocrit <28% to maintain a hematocrit level not exceeding 30%. The maximal dose of epoetin-α or β was 20 000 U per month. The target haemoglobin range and dose limitation for ESAs were the same for dialysis CKD patients. Thus, long before randomized controlled trials showing an increased risk for cardiovascular events at nearly normal haemoglobin concentrations and higher ESA doses in CKD, nephrologists in Taiwan had avoided the use of disproportionately high dosages of ESAs to achieve a haemoglobin level of 10-11 g/dL. Moreover, intravenous iron supplementation was encouraged earlier in Taiwan in 1996, when we reached consensus on the diagnostic criteria for iron deficiency (serum ferritin <300 ng/mL and/or transferrin saturation <30%). The experience of CKD anaemia management in Taiwan demonstrated that a reasonable haemoglobin target can be achieved by using the lowest possible ESA dose and intravenous iron supplementation.
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Affiliation(s)
- Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Buddhist Tzu Chi University, Taipei, Taiwan
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Bickford AK. Evaluation and treatment of iron deficiency in patients with kidney disease. NUTRITION IN CLINICAL CARE : AN OFFICIAL PUBLICATION OF TUFTS UNIVERSITY 2002; 5:225-30. [PMID: 12455224 DOI: 10.1046/j.1523-5408.2002.05504.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Iron deficiency is common in patients with kidney disease and is one of the primary causes for decreased response to recombinant human erthropoietin (rHuEPO) therapy. Serum ferritin and percent tranferrin saturation are regarded as the preferred indirect measurements of iron status. The National Kidney Foundation-Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines recommend levels of > 100 ng/ml and > 20%, respectively. These tests, however, have practical limitations and lack sensitivity and specificity to identify "functional" iron deficiency, which can occur in the presence of normal or even increased iron stores. Newer methods of assessing iron status are becoming available, with reticulocyte hemoglobin content (CHr) showing the most promise at this time. K/DOQ1 guidelines recommend that adequacy of iron should be based on the amount of iron needed to sufficiently achieve target hemoglobin and hematocrit levels of 11-12 g/dL, or 33-36%. Studies have demonstrated for a majority of hemodialysis and some predialysis and peritoneal dialysis patients that intravenous iron therapy is necessary to improve response, thus reducing the amount of rHuEPO needed to achieve these goals. Though intravenous iron is generally regarded as safe and effective, caution should be taken in regard to acceptable amounts of supplementation and long-term effects with the potential risk of iron overload.
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Affiliation(s)
- Andrea K Bickford
- Fresnius Medical Care Central Dupage Dialysis Center, 25 N. Winfield Road, Winfield, IL 60190, USA.
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Abstract
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.
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Affiliation(s)
- J Q Hudson
- Department of Clinical Pharmacy, University of Tennessee, Memphis 38163, USA.
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Abstract
Each month, subscribers to The Formulary® Monograph Service receive five to six researched monographs on drugs that are newly released or are in late Phase III trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation (DUE) is also provided each month. The monographs are published in printed form and on diskettes that allow customization. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board called The Formulary Information Exchange (The F.I.X). All topics pertinent to clinical pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The April 2001 Formulary monographsare on caspofungin, peginterferon alfa-2b, ziprasidone, 90Y ibritumomab tiuxe-tan, and Abarelix depot. The DUE is on caspofungin.
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Affiliation(s)
| | - Terri Levien
- Drug Information Pharmacist, Drug Information Center, Washington State University at Spokane
| | - Danial E. Baker
- Drug Information Center and College of Pharmacy, Washington State University at Spokane, 601 West First Avenue, Spokane, WA 99201-3899
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Goicoechea M, Caramelo C, Ochando A, Andrea C, Garvía R, Ortiz A. Antiplatelet therapy alters iron requirements in hemodialysis patients. Am J Kidney Dis 2000; 36:80-7. [PMID: 10873876 DOI: 10.1053/ajkd.2000.8275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hemodialysis (HD) patients are prone to develop iron deficiency because of consumption of iron stores during erythropoietin (EPO) therapy. Data are needed to establish the factors involved in the different iron needs among these patients. Sixty-five HD patients were prospectively studied during a year. The subjects were dialyzed through polytetrafluoroethylene (PTFE) grafts (n = 23), arteriovenous native fistulae (n = 41), and a Permcath (n = 1). Twenty-four patients were administered aspirin; 23 patients, ticlopidine; 1 patient, dipyridamole; and 4 patients, anticoagulation with acenocoumarol. Iron supplementation (oral or parenteral) and laboratory parameters were recorded monthly. Significant differences in iron requirements, depending on the use of antiplatelet and/or anticoagulation agents, were found. Total parenteral iron supplements were greater in patients on antiplatelet therapy with either native or graft vascular accesses compared with the rest (2,406 +/- 1,445 versus 1,562 +/- 858 mg; P = 0.0081). Twelve of 52 patients on antiplatelet therapy required oral iron and only 1 of 13 patients not on antiplatelet therapy was administered oral iron supplements (P < 0.05). Patients on antiplatelet therapy were administered more transfusions (1.9 +/- 3.8 transfusions/y) than individuals not on antiplatelet therapy (0.15 +/- 0.3 transfusions/y; P = 0.0015). However, only patients with PTFE grafts on antiplatelet therapy had a post-HD bleeding time longer than patients not on antiplatelet therapy (9.1 +/- 3.6 versus 5.7 +/- 3.9 minutes; P < 0.0001). Multiple logistic regression analysis showed that the use of antiplatelet agents (P < 0.05) is an independent factor that increased the probability of requiring greater parenteral iron supplements (>2.5 g/y). Patients with PTFE grafts required more EPO than those with autologous fistulae (160 +/- 93 versus 100 +/- 63 U/kg/wk; P = 0.012). No differences between groups were found that could explain this finding. Antiplatelet and/or anticoagulation therapy implied the use of greater amounts of iron supplements in HD patients. Although these greater requirements of iron occurred in parallel with bleeding from the vascular access, additional data favor the existence of other factors, eg, interdialytic blood losses. The present study suggests that antiplatelet therapy may be an important factor in determining iron requirements in HD patients. Moreover, our data relate for the first time the use of prosthetic grafts with increased EPO requirements, an issue of great potential importance in the debate about vascular access policy in dialysis units.
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Affiliation(s)
- M Goicoechea
- Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain
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Bailie GR, Johnson CA, Mason NA. Parenteral iron use in the management of anemia in end-stage renal disease patients. Am J Kidney Dis 2000; 35:1-12. [PMID: 10620537 DOI: 10.1016/s0272-6386(00)70294-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- G R Bailie
- Nephrology Pharmacy Associates, Inc, Ann Arbor, MI, USA.
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Tarng DC, Wei YH, Huang TP, Kuo BI, Yang WC. Intravenous ascorbic acid as an adjuvant therapy for recombinant erythropoietin in hemodialysis patients with hyperferritinemia. Kidney Int 1999; 55:2477-86. [PMID: 10354297 DOI: 10.1046/j.1523-1755.1999.00479.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Inadequate iron mobilization and defective iron utilization may cause recombinant erythropoietin (rEPO) hyporesponsiveness in hemodialysis (HD) patients with iron overload. We have demonstrated that intravenous ascorbic acid (IVAA), but not intravenous iron medication, can effectively circumvent the functional iron-deficient erythropoiesis associated with iron overload in HD patients. However, it is uncertain whether all HD patients with hyperferritinemia will consistently respond to IVAA and which index may indicate functional iron deficiency in the special entity. Therefore, a prospective study was conducted to establish the guidelines for IVAA adjuvant therapy. METHODS Sixty-five HD patients with serum ferritin levels of more than 500 microgram/liter were recruited and divided into the control (N = 19) and IVAA (N = 46) groups. IVAA patients with a hematocrit (Hct) of less than 30% received 300 mg of ascorbic acid three times per week for eight weeks. Controls had a Hct of more than 30% and did not receive the adjuvant therapy. Red blood cell and reticulocyte counts, iron metabolism indices, erythrocyte zinc protoporphyrin (E-ZPP), and the concentrations of plasma ascorbate and oxalate were examined before and following the therapy. RESULTS Thirteen patients (four controls and nine IVAA patients) withdrew by the end of the study. Eighteen patients had a dramatic response to IVAA with a significant increase in their hemoglobin and reticulocyte index and a concomitant 24% reduction in rEPO dose after eight weeks. This paralleled a significant rise in serum iron and transferrin saturation (TS) and a fall in E-ZPP and serum ferritin (baselines vs. 8 weeks, serum iron 68 +/- 37 vs. 124 +/- 64 microgram/dl, TS 27 +/- 10 vs. 48 +/- 19%, E-ZPP 123 +/- 44 vs. 70 +/- 13 micromol/mol heme, and serum ferritin 816 +/- 435 vs. 587 +/- 323 microgram/liter, P < 0. 05). Compared with responders, mean values of hemoglobin, rEPO dose, iron metabolism parameters, and E-ZPP showed no significant changes in controls (N = 15) and in non-responders (N = 19). Thirty-seven patients (18 responders and 19 non-responders) were further analyzed by receiver operating characteristic curves to seek the criteria for prediction of a response to IVAA treatment. The results showed that E-ZPP at a cut-off level of more than 105 micromol/mol heme and TS at a level of less than 25% were more specific to confirm the status of functional iron deficiency in iron-overloaded patients. The two criterion values had the highest accuracy to predict a response to treatment. CONCLUSIONS Functional iron-deficient erythropoiesis plays a role in rEPO-hyporesponsive anemia in HD patients with hyperferritinemia. IVAA may be an adjuvant therapy for rEPO in these patients, and E-ZPP of more than 105 micromol/mol heme and TS of less than 25% should be used to guide the IVAA treatment.
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Affiliation(s)
- D C Tarng
- Institute of Clinical Medicine, Department of Biochemistry, National Yang-Ming University, Taipei, Taiwan
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