Treating Patients With IV Iron Therapy: Special Considerations
ANNA CE Satellite Symposium - Las Vegas, Nevada , April 21, 2005

Panel Discussion

Dr. Fishbane
Dr. Warady
Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.


Please comment: EPO is married to iron and they cannot divorce. They need each other.
How to treat a patient who is a diabetic and who has a transferrin saturation of 15%, ferritin of greater than 1000, and a hemoglobin of 10.4, but who requires 20,000 units of EPO per treatment?
The Fudin study showed that there was in increase in hemoglobin from 8 to 11 in 26 months with use of IV iron with no EPO treatment at all. Could this be maintained? Is EPO necessary in every patient with chronic kidney disease?
Has any anyone done evidence-based studies on the use of oral iron polysaccharide?
What are your thoughts about holding IV iron during the course of antibiotic therapy during the presence of infection?
We said that iron should not be given during an infection, but what kinds of infection are we talking about?
Do you have any data on the treatment of IV iron in peritoneal dialysis patients?
It is great to use less EPO, but what long-term effect might high serum ferritin levels have on our patients?
What role might IV vitamin C have?
What do you suggest for patients who are allergic to iron, patients who are severely anemic and already receiving large EPO doses?
What is the role of IV iron therapy in the predialysis population and in PD?

Panelist Responses
(Back to question index)

Please comment: EPO is married to iron and they cannot divorce. They need each other.

Dr. Fishbane: This is a reality. They have to do some juggling though. I think this is a nice allusion to the relationship between 2 two agents.

(Back to question index) How to treat a patient who is a diabetic and who has a transferrin saturation of 15%, ferritin of greater than 1000, and a hemoglobin of 10.4, but who requires 20,000 units of EPO per treatment?

Dr. Fishbane: This is somebody that is not responding well at all to EPO treatment. The question was to continue a maintenance dose of 62.5 mg of iron or increase it. It would seem to me that the key point here is if you are convinced that the patient is not infected, it would be worthwhile, because of the EPO resistance, to try a course of additional IV iron in such a patient.

(Back to question index)
The Fudin study showed that there was in increase in hemoglobin from 8 to 11 in 26 months with use of IV iron with no EPO treatment at all. Could this be maintained? Is EPO necessary in every patient with chronic kidney disease?

Dr. Fishbane: The answer I suppose is that it is variable. A lot of patients starting dialysis still produce a lot of their own erythropoietin. In those patients, it may be that treatment with IV iron alone could be effective. Don Silverberg has also shown this in CKD, the exact same findings, that IV iron by itself even without EPO worked. I do not think it is very sensible treatment though. It seems to me that both EPO and iron are married, and therefore should be used together, and this is the most effective chance we have for treatment.


(Back to question index)
Has any anyone done evidence-based studies on the use of oral iron polysaccharide?

Dr. Fishbane: I guess I will try to answer in one of two ways. If the question refers to iron polysaccharides such as Niferex, the answer is there have been randomized control trials in hemodialysis patients that demonstrate no efficacy of that agent compared to placebo. If the question is intended to be about HIP or proferrin, which is heme-iron polypeptide, there is one published study that I know of, that showed that that particular agent does seem to have some efficacy. Not quite as much IV iron, but it looks like it is a promising agent, although additional studies need to be done to have a reasonable base of evidence.

(Back to question index)
What are your thoughts about holding IV iron during the course of antibiotic therapy during the presence of infection?

Dr. Fishbane: Sure. I think it is very reasonable therapy to stop iron. IV iron treatment can be held and in 2 weeks when the infection is better, you can treat the iron deficiency at that point.

(Back to question index)
We said that iron should not be given during an infection, but what kinds of infection are we talking about?

Dr. Fishbane: This is a good question, as one that I am not sure that I have an absolute answer for. If the patient has acute bacteremia with positive blood cultures, that is a setting where bacteria are living in the bloodstream, and providing iron into the bloodstream at this point would seem to be something that we would like to avoid. I would not give IV iron with bacteremia. At the far other extreme, if somebody’s infection is a sore throat and runny nose, I certainly would be very comfortable giving iron in that setting, but in the middle we recognize that there are a lot of murky situations, such as people with smoldering leg ulcers. It is really an issue of judgment in such cases.

(Back to question index)
Do you have any data on the treatment of IV iron in peritoneal dialysis patients?

Dr. Fishbane: I have just had the opportunity to review this literature as part of K/DOQI, and I have concluded that there is not a lot that has much value. There were 2 studies that seemed to have reasonable value in PD. They show that IV iron does have effectiveness. The better of the 2 studies, by Johnson et al, that randomized the patients to either oral or IV iron treatment, showed that IV iron is clearly more effective for patients on PD, but they showed that oral iron was fairly effective as well, not as effective, but compared to hemodialysis patients where oral iron has no demonstrable efficacy at all, in peritoneal dialysis oral iron may be a very reasonable first-line agent.

(Back to question index)
It is great to use less EPO, but what long-term effects might high serum ferritin levels have on our patients?

Dr. Fishbane: It is a good question, and because of this we need to treat with IV iron with reasonable goals. The reason for having upper targets like the current K/DOQI 800 ng/mL ferritin level is that most patients simply should not be maintained at levels higher than that based on our current knowledge. We should not try to achieve extremely high values, and the reason I showed you the studies that I did is simply to suggest to you that there are some patients that you have in which it would be appropriate to treat with IV iron.

A very interesting question, and I know I have dealt with this, is how to treat patient with a 14 or 15 g/dL hemoglobin level, so they have a great hemoglobin, but at the same time they have very low iron numbers. Partially that is not very surprising because iron has simply been shifted from circulation and from storage into red blood cells. Having a very high hemoglobin concentration means you have taken a lot of iron and put it into red cells, but the patient will suffer some ill consequences of iron deficiency for all the cells of the body that need iron for normal function. My suggestion is in fact to treat that patient with IV iron. Let me say that again. It is a recommendation to treat that patient with IV iron to avoid severe iron deficiency.

(Back to question index)
What role might IV vitamin C have?

Dr. Fishbane: Several of you asked this question in different ways and the answer is that vitamin C has a role, when given intravenously, of allowing iron to get out of storage tissues more effectively and it also may be improving oral absorption of iron. Vitamin C could be effective. I am a little cautious with it because every drop of vitamin C that you give gets converted to oxalic acid and you might remember that oxalosis is a potential complication at least in people with kidney disease. If it is going to be used, it should be used, I think, for short courses. The general nephrology dietary recommendations for vitamin C are less than 50 mg/day. You need to use some caution.

(Back to question index)
What do you suggest for patients who are allergic to iron, patients who are severely anemic and already receiving large EPO doses?

Dr. Fishbane: In the patient who has allergy to iron, who does not tolerate iron, there are differences between the agents. If it is an iron dextran allergic patient, very likely that patient will tolerate the newer agents, such as ferric gluconate. It would be reasonable with good observation to treat that patient. If the patient previously on iron dextran had a severe anaphylactic reaction, you cannot be overly casual about this. You cannot simply give Ferrlecit in the unit. You may want to observe that patient in the hospital with treatment. If the patient had low-grade reactions with iron dextran, it would be reasonable to treat the patient with ferric gluconate or iron sucrose in the dialysis unit. If the patient is allergic to all of the IV iron agents, it is very clear you have nothing to use then. Rather than go through desensitization in trying to battle allergy, I would simply do everything I can to try to make oral iron more effective, make sure the patient takes it between meals so that it will get absorbed, consider vitamin C to improve effectiveness, avoid the enteric-coated forms of oral iron, so that iron can get absorbed in the proper absorbing segments within the intestines. You have the possibility then that you could achieve effectiveness.

(Back to question index)
What is the role of IV iron therapy in the predialysis population and in PD?

Dr. Warady: For pediatrics, I can tell you there is no randomized trial. I have looked at that. Clearly, in children, many of these children do not like to take the iron, they get GI upset with the iron. We know despite the fact that we prescribe appropriate doses of oral iron, they are not receiving those doses. I think there clearly is a role for IV iron in those children. Many of the kids that I have on PD do in fact come in on an intermittent basis for an IV iron infusion and we see a clear impact on repleting their iron status. I think that we need to monitor that, and we need to use IV iron as another approach even in the non-hemodialysis patient. I think there is data in adults in terms of larger doses to give those patients.

Dr. Fishbane: In patients with chronic kidney disease for adults who have nondialysis dependent CKD, chronic kidney disease that has not reached end-stage renal disease, it is my opinion that IV iron is often very effective. We use it where part of normalization of hemoglobin study where we are rising hemoglobin levels to 13.5, many of those patients do not get there unless you treat with IV iron and anecdotally, by my observation, patients seem to respond very nicely. In the literature there are at least 8 published studies in CKD that involve the use of IV iron, 6 of them do not have very great value, 2 of them are reasonable studies though. The literature is not great. One of these studies shows oral iron to be about as effective as IV iron, which is surprising. The other shows thar IV iron is quite a bit more effective, but it is a very thin literature of studies. There is great need for additional studies. We are part of a study that hopefully will see results from it published within the next year or so.




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