Abstract
Anaemia in chronic kidney disease (CKD) is a complex disease that requires an integrated approach to incorporate both diagnostic and therapeutic interventions and to address the different facets of its aetiology and pathophysiology. The advent of erythropoiesis stimulating agents (ESA) has revolutionised the therapy of anaemia of CKD, and has resulted in a significant decline in the need for blood transfusions in CKD patients. The routine application of ESA has also led to the need for concomitant iron supplementation. ESA and iron therapy now form the cornerstone of anaemia management in CKD. Intravenous iron administration is effective with acceptable safety, and may improve ESA responsiveness. However, less is known about the long-term safety of iron supplementation in CKD patients. Whereas maintenance (weekly to monthly) intravenous iron has been routinely used in maintenance dialysis patients, iron replacement in patients with non-dialysis-dependent CKD is less well studied, in spite of the much larger number of patients affected. This review discusses iron supplementation in CKD with an emphasis toward controversial issues that continue to pose dilemmas in clinical practice. Concerns related to both the optimal amount of iron supplementation and to the safety of various agents available in clinical practice are presented.
Highlights
Anaemia is a common complication of chronic kidney disease (CKD) and is associated with poor outcomes including higher death risk in both maintenance dialysis patients (Regidor et al 2006), and in individuals with non-dialysis-dependent CKD stages 3 to 5 (Kovesdy et al 2006)
We review our current understanding about what an optimal iron level means and discuss currently available IV iron products, together with the various concerns related to potential adverse effects of therapeutic iron administration
CKD patients may lose iron as a result of gastrointestinal or other bleeding, frequent blood testing or blood losses related to haemodialysis, and erythropoiesis stimulating agent (ESA) use has magnified the absolute or relative iron deficiency caused by such losses (Kalantar-Zadeh et al 2009a)
Summary
Anaemia is a common complication of chronic kidney disease (CKD) and is associated with poor outcomes including higher death risk in both maintenance dialysis patients (Regidor et al 2006), and in individuals with non-dialysis-dependent CKD stages 3 to 5 (Kovesdy et al 2006). Optimal iron management involves the administration of enough iron to assure unhindered erythropoiesis (provided enough erythropoietin is available), but avoids deleterious consequences that are either the result of too much iron (irrespective of the therapeutic agent), or, that are related to reactions that are specific to the particular agent used. We review our current understanding about what an optimal iron level means and discuss currently available IV iron products, together with the various concerns related to potential adverse effects of therapeutic iron administration. CKD patients may lose iron as a result of gastrointestinal or other bleeding, frequent blood testing or blood losses related to haemodialysis, and ESA use has magnified the absolute or relative iron deficiency caused by such losses (Kalantar-Zadeh et al 2009a). Transferrin saturation ratio (iron saturation ratio)a Serum iron Reticulocyte haemoglobin content Percentage of hypochromic red cells Soluble transferrin receptor Erythrocyte zinc protoporphyrin Hepcidin
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