Abstract
Aims: To evaluate erythropoietic response rates to oral iron over time in iron-deficient anemic patients with nondialysis-dependent chronic kidney disease (ND-CKD). Materials and methods: FIND-CKD was a 1-year, randomized, multicenter trial of iron therapy in patients with ND-CKD, anemia, and iron deficiency, without erythropoiesis-stimulating agent (ESA) therapy. Patients with active infection or C-reactive protein > 20 mg/L were excluded. In this post-hoc analysis, response was defined as ≥ 1 g/dL increase in hemoglobin (Hb) from baseline, before initiation of alternative anemia therapy (i.e., ESA, transfusion, or intravenous iron). Results: 308 patients received oral iron (200 mg elemental iron/day). Mean (SD) Hb at baseline was 10.4 (0.7) g/dL. At week 4, Hb data were available from 292 patients without alternative anemia therapy: 63/292 (21.6%) showed a response. Among the 229 nonresponders at week 4, 48.8% showed a cumulative response on ≥ 1 occasion by week 52 (11.1%, 19.9%, 25.9%, and 28.7% had a response at weeks 8, 12, 24, and 52, respectively), and 27.9% had received alternative iron therapy by week 52. Baseline levels of Hb, ferritin, and transferrin saturation were lower in responders than in nonresponders. Neither concomitant medication nor adherence (as assessed by medication count) was substantially different between early responders and nonresponders. Conclusion: Four weeks after starting oral iron therapy, only 21.6% of anemic patients with ND-CKD and iron deficiency showed an Hb increase of at least 1 g/dL. Among early nonresponders, < 30% responded at any subsequent time point. Earlier consideration of alternative therapy could improve anemia management in this population.
Highlights
Iron deficiency is an important contributory factor in the pathogenesis of anemia in patients with nondialysis-dependent chronic kidney disease (ND-CKD)
Oral iron supplementation is widely used in anemic ND-CKD patients with iron deficiency; results from this large, prospective study highlight the limited efficacy of this approach, with only 21.6% of patients having responded four weeks after continuous treatment with oral iron
There was a gradual increase in the proportion of responders to oral iron but this lessened over time, and more than half of the patients who did not respond by week 4 never achieved an Hb increase of at least 1 g/dL during the year-long study
Summary
Iron deficiency is an important contributory factor in the pathogenesis of anemia in patients with nondialysis-dependent chronic kidney disease (ND-CKD). The Kidney Disease Improving Global Outcomes (KDIGO) recommendations suggest that iron therapy should be used in patients with ND-CKD to correct iron deficiency, either alone or prior to starting erythropoiesis-stimulating agent (ESA) therapy [4]. In patients who are unable to absorb adequate oral iron, or if more rapid anemia correction is required, IV iron can be initiated. It would be helpful to understand what proportion of early nonresponders may respond later and, ideally, to predict which patients are unlikely to ever respond Such information could help to reduce unnecessary delay in switching therapy and correcting anemia. Data from the intervention groups, in which patients received FCM, are shown for comparative purposes in a descriptive manner
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