Towards Better Control in CKD:
Improving Anemia Management


ANNA CE Satellite Symposium - New Orleans, Louisiana, October 17, 2004

Panel Discussion
Joel D. Glickman, MD
David B. Van Wyck, MD
Michelle Turgeon, MSW
Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.


Do you advocate iron saturation levels of greater than 25% or 30% rather than just 20% to decrease use of EPO?
Please comment on the recent Kidney Int articles addressing free radicals secondary to iron therapy and the potential risk of morbidity from free radicals.
Do you hold parenteral iron for a fever of unknown etiology?
How often do you make dose changes if you are drawing the hemoglobin weekly?
In your comments regarding the effectiveness of IV iron sucrose compared to epoetin alfa alone, why is the dose of epoetin alfa 2000 units per week utilized when the actual dose should be closer to 10,000 units per week, this is in the CKD patients?
Michelle, you noted size and number of patients at all clinics in your examples of the clinics with the worst anemia management outcomes. You did not directly address the number of patients anemia managers are responsible for?
Any studies on doses of IV iron sucrose greater than 200 mg over 5 minutes? For example, 500 mg iron sucrose IV in normal saline x2 doses administered over 1 hour?

Panelist Responses
(Back to question index)

Do you advocate iron saturation levels of greater than 25% or 30% rather than just 20% to decrease use of EPO?

Dr. Joel Glickman: I focus more on ferritin levels. I think that the iron saturation measurement is so variable that it cannot be interpreted on its own. It needs to be interpreted in the context of the ferritin level. I personally focus a little bit more on the ferritins, and I also look at the hemoglobins too. We are not treating iron, we are treating anemia. Our focus has to be on anemia. Depending on what the hemoglobin level is, depending what erythropoietin dose is, and depending what the ferritin dose is, I put all those factors together to look at the saturations, so I do not look solely at saturations.

(Back to question index) Please comment on the recent Kidney Int articles addressing free radicals secondary to iron therapy and the potential risk of morbidity from free radicals.

Dr. Van Wyck: As I explained about the safety and bioactivity, you can imagine that an IV iron challenge is a bioactive iron challenge. It is an oxidative stress challenge. As you administer IV iron to the patient in any setting, you are giving an oxidative stress challenge. In the scheme of what we are doing, it is not very much, it is very transient and at best. There have been a series of articles in Kidney Int and JASN in the nephrology literature about oxidative stress, but probably the best one is from Austria; they looked at oxidative stress on dialysis in patients given or not given IV iron. In short, they found that the oxidative stress of dialysis itself masked any additional oxidative stress, any discernible oxidative stress in the IV iron challenge. That is to say that you can get oxidative stress from IV iron, but its magnitude is lost in the noise of oxidative stress that the dialysis patient gets, and that is the way I think about acute IV iron dosing. The toxicity data that I have seen has all been at doses way higher than anybody can imagine giving to a human being - on the order of 5, 10, 30 times more than you would give to humans, so I do not know what to make of it. I do worry about oxidative stress and when I worry about oxidative stress, I worry about ferritins greater than 800.

(Back to question index)
Do you hold parenteral iron for a fever of unknown etiology?

Dr. Joel Glickman: Yes, if I have a fever of unknown etiology, I am strongly suspicious that that person has some chronic inflammatory disease - in all likelihood, I am going to be holding iron for a while. Occasionally, I will have a patient who is severely, severely anemic and severely iron deficient, and I will give them a couple of doses of iron because I think it is important to get the hemoglobin level up. I will hedge on that patient, but if there is a fever and I worry about chronic inflammatory disorder, I will not put them on their usual iron dosage.

Dr. Van Wyck:
I agree with Joel.


(Back to question index)
How often do you make dose changes if you are drawing the hemoglobin weekly?

Ms. Michelle Turgeon: Excellent question. This is something that Gambro came up with this year, we do draw hemoglobins weekly on all patients, and we do dose weekly. Our theory on that is, if a patient - you give them an amount of Epogen and that is going to sustain them, then you will not have a spike either way in their hemoglobin, you just keep them at that level of dose. Some can say you are chasing your tails, I know it takes so many days for the epogen to work to make red blood cells, but according to our protocol, that is what we follow. It is a Gambro initiative. We are drawing weekly hemoglobins and dosing weekly. So far we have not seen a major problem. The only thing is that with our protocol, it is very aggressive, so sometimes we do have a lot of patients with Hb values greater than 13 g/dL, and we just need to be aggressive in titrating them down or put epogen on hold. Good question.


(Back to question index)
In your comments regarding the effectiveness of IV iron sucrose compared to epoetin alfa alone, why is the dose of epoetin alfa 2000 units per week utilized when the actual dose should be closer to 10,000 units per week, this is in the CKD patients?

Dr. Joel Glickman: I did not do the study. It is interesting, I do not know why they picked that dose, but they did and it worked. I think that the lesson there may be that if you use IV iron, you may get away with just 2000 units per week, as opposed to having iron-deficient erythropoiesis where you are going to need much more epogen, so that may be the answer there.

(Back to question index)
Michelle, you noted size and number of patients at all clinics in your examples of the clinics with the worst anemia management outcomes. You did not directly address the number of patients anemia managers are responsible for?

Ms. Michelle Turgeon: Excellent question. In my clinics the anemia managers are the Center Directors (CDs). For 42 patients in one clinic, the anemia manager, who in this case is the CD, focuses on all 42 patients. I do have a large clinic where the CD has 118 hemo and 20 PD patients, and she handles anemia dosing for all of them. But she has a charge nurse and 11 nursing staff that she will delegate to help put in the orders.

(Back to question index)
Any studies on doses of IV iron sucrose greater than 200 mg over 5 minutes? For example, 500 mg iron sucrose IV in normal saline x2 doses administered over 1 hour

Dr. Van Wyck: On review of the literature experience with IV iron doses and time of infusion - those are the things that you need to know in order to pick a dose, and particularly, to pick a high dose; the information is on the next to last slide in my presentation; the data show IV iron agents, review of the literature, and the 500-mg doses of iron sucrose that are associated with little or no rates of adverse events are when the dose has been given over 3-1/2 to 4 hours, so those are long infusions with iron sucrose at 500 mg. We know that people do give such larger doses, and we know that there is a lot of literature about 500-mg doses. There are even trials comparing 500-mg dosing of iron sucrose and iron dextran, but I find it inconvenient to sit a patient down for a long period of time for such a long infusion. I would rather give a smaller dose over a shorter time interval.




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