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Volume 3 September 20, 2006 Number 9

An Exclusive Continuing Education Publication of Acadiana Consultant Pharmacy Service
Author, Publisher, Editor-in Chief, Typesetter & Printer, Charles S. Feucht,PD,FASCP PharmD candidate

Medication News & Update

Requirement for Iron Therapy in Hemodialysis Patients Receiving Erythropoietin Question

Should hemodialysis patients who are being treated with human erythropoietin also receive iron therapy?

Response from  Daniel W. Coyne, MD 
Professor of Medicine, Washington University, St. Louis, Missouri

Generally, yes. Patients on hemodialysis have ongoing blood (and therefore iron) loss from the dialysis circuit itself, vascular access and other procedures, gastrointestinal blood loss, and frequent blood draws. Hemodialysis patients lose an estimated 1-3 g of iron annually.[1]

Oral iron therapy is not usually efficacious in hemodialysis patients.[2] Studies of various designs have administered forms of intravenous (IV) iron in multiple dosages and frequencies. Virtually all have demonstrated IV iron is cost effective and improves achieved hemoglobin and/or reduces the required dose of erythropoietic agent.[3,4]

Patients starting hemodialysis are frequently overtly iron deficient, despite seemingly satisfactory ferritin values. Fudin and colleagues[5] found absent iron stores on bone marrow aspiration in patients starting dialysis despite ferritin values ranging from approximately 80-480 ng/mL. Therefore, a 1-g loading dose of iron to replete iron stores and provide iron for the desired increase in hemoglobin is frequently indicated in new patients. The 1-g load is usually administered as 8 to 10 divided doses over consecutive dialysis treatments. A loading dose of iron should also be considered in patients who have large blood losses or have had their maintenance iron held and are now anemic or requiring higher doses of erythropoietic agent. Thereafter, consider giving a maintenance weekly dose of 20-60 mg iron to replace ongoing iron losses. Unless inflammation or infection occurs, serum ferritin should stabilize between 200 and 800 ng/mL in most patients.[6] To avoid unnecessary iron overload, maintenance iron therapy should be withheld if transferrin saturation exceeds 50%. This is a prudent safety stop point recommended by both the 1997 and 2001 KDOQI anemia workgroups.[1,7]



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