More than a Decade of Experience and Still No Consensus

Abstract

During the past decade, the integration of recombinant human erythropoietin (EPO) and maintenance intravenous iron therapy into standard anemia management protocols has significantly altered the treatment of anemia in patients who are on hemodialysis (HD). Hemoglobin levels have increased inexorably and now average almost 12 g/dl (1). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines state that intravenous iron usually is required for the provision of optimal iron stores to maximize erythropoiesis-stimulating agent (ESA) efficiency in patients who are on dialysis (2). Intravenous iron therapy is needed in patients who are on HD because these patients experience ongoing blood (iron) losses, and oral iron fails to maintain adequate iron stores. Efficient erythropoiesis requires both iron and erythropoietin (2). In these patients, intravenous iron improves iron and hematologic parameters, with health benefits of intravenous iron outweighing potential adverse effects. Use of maintenance iron improves patients’ response to EPO therapy (3), replaces patients’ ongoing iron losses, and helps to maintain patients’ target hemoglobin and hematocrit ranges. These benefits of intravenous iron therapy have been achieved at storage iron levels far below those that generally were seen with transfusions in the pre-EPO era (4). However, according to Medicare claims data from the US Renal Data System, only slightly more than half of HD patients receive intravenous iron therapy at least once a month, demonstrating that although intravenous iron therapy is being administered to the majority of HD patients, it may not be used on a regular basis (5). Although the reasons for lack of “regular” intravenous iron may be many, such as concerns about iron parameters, particularly ferritin levels, it also may reflect variation in protocols among centers. The KDOQI guidelines were a milestone in the development of effective, standardized principles for the management of anemia in patients with chronic …