Relationships between iron dose, hospitalizations and mortality in incident haemodialysis patients: a propensity-score matched approach

Varas, Javier; Ramos, Rosa; Aljama, Pedro; Pérez‐García, Rafael; Moreso, Francesc; Pinedo, Miguel; Merello, José Ignacio; Stuard, Stefano; Canaud, Bernard; Martín‐Malo, Alejandro

doi:10.1093/ndt/gfx209

Cited by 7 publications

(2 citation statements)

References 47 publications

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“…If sufficient iron is not available for erythropoiesis, this can lead to inappropriate escalation of erythropoiesis-stimulating agent (ESA) therapy, which is associated with adverse outcomes in both adults and children [5–8]. Conversely, iron overload also has negative sequelae including free radical tissue damage, increased risk of systemic infection, and more hospitalizations [9–11]. Achieving the optimal balance of bioavailable iron for erythropoiesis in children with advanced CKD is therefore paramount in anemia management; however, it remains challenging for pediatric nephrologists.…”

Section: Introductionmentioning

confidence: 99%

Measurement of iron status in chronic kidney disease

Hayes

2018

Pediatr Nephrol

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Anemia is a common complication of chronic kidney disease (CKD) in children, and dysregulation of iron homeostasis plays a central role in its pathogenesis. Optimizing iron status is a prerequisite for effective treatment of anemia. Insufficient iron can lead to inappropriate escalation of the erythropoiesis-stimulating agent (ESA) dose, which is associated with adverse outcomes. Excess iron supplementation also has negative sequelae including free radical tissue damage and increased risk of systemic infection. Notwithstanding the importance of optimizing bioavailable iron for erythropoiesis for children with advanced CKD, achieving this remains challenging for pediatric nephrologists due to the historical lack of practical and robust measures of iron status. In recent years, novel techniques have come to the fore to facilitate accurate and practical assessment of iron balance. These measures are the focus of this review, with emphasis on their relevance to the pediatric CKD population.

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Section: Introductionmentioning

confidence: 99%

Measurement of iron status in chronic kidney disease

Hayes

2018

Pediatr Nephrol

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“…The same group [30] observed no consistent association between IV iron dose and risk for all-cause, cardiovascular, or infectious hospitalizations, even among patients receiving iron doses exceeding 2100 mg over a period of 6 months. A new multicenter observational study of the safety of IV iron supplementation in incident HD patients showed that larger iron doses infused over time were not associated with mortality, after adjusting for potential confounding factors [31]. Furthermore, a recent systematic review and meta-analysis of 7 randomized controlled trials and 15 observational studies including more than 140,000 patients treated with HD, found no evidence of increased risk of infection, cardiovascular events, hospitalizations, or mortality with the use of higher-dose IV iron compared with lower doses [32].…”

Section: Discussionmentioning

confidence: 99%

Achievement of renal anemia KDIGO targets by two different clinical strategies – a European hemodialysis multicenter analysis

Drożdż¹,

Weigert

Silva

et al. 2019

BMC Nephrol

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BackgroundThe optimal treatment algorithm for iron therapy and the use of erythropoiesis-stimulating agents (ESA) in anemic hemodialysis (HD) patients has not been established. Hemoglobin (Hb) target levels can be achieved through more frequent intravenous (IV) iron use with lower ESA dose, or with less iron dosing but higher ESA. ESA therapy to correct anemia may result in severe arterial and venous thrombotic complications and the evidence base evaluating hard clinical outcomes related to the use of IV iron is sparse.MethodsA total of 1247 maintenance HD patients from 12 dialysis centers in Portugal (n = 730) and Poland (n = 517) were considered. We assessed achievement of KDIGO renal anemia targets with focus on treatment strategies, which typically differ between countries. In Poland the use and dose of IV iron was 35–72% higher than that in Portugal (p < 0.001) during three consecutive months; use and dose of ESA was 61% higher in Portugal (5034 vs 3133 IU (adjusted)/week, p < 0.001).ResultsMean Hb concentration was similar (11.0 vs 11.0 g/dL) in patients treated in both countries and the proportion of patients within KDIGO anemia target was 69.5% in Poland vs 65.8% in Portugal (NS). Ferritin and TSAT levels and the proportion of patients with TSAT > 20 and > 50% were both significantly higher in patients in Poland (88.8 and 14.6%) than in Portugal (76.3 and 5.7% respectively, p < 0.001). Significantly more patients in Poland had a ferritin concentration > 800 μg/L (35.6%) compared to Portugal (15.8%, p < 0.001). The ESA resistance index (ERI) was significantly higher in patients treated in Portugal (p < 0.001). Correlation analyses showed confounding by treatment indication in unadjusted models. Multiple and logistic regression analyses showed that with ferritin within KDIGO recommended range of 200–800 μg/L the odds for Hb within guidelines increased significantly. Annual gross mortality was 16% in Poland and 13% in Portugal (NS); there were no differences in cause-specific mortality.ConclusionsAdministration of high doses of IV iron in routine clinical HD practice may not be associated with considerable harm. However, large randomized controlled trials are needed to provide absolute evidence of iron safety.

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