• Roger S. Iron. Nephrology 2006 Apr;11(S1):S217-29.



• Roger S. Iron. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Aug. 24 p. [58 references]

This is the current release of the guideline.

Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.

Guidelines

Assessment of iron prior to and after commencement of synthetic erythropoietic

Stimulating proteins (referred to as epoetin):

1. Dialysis patients should have regular assessment of iron stores and availability, as iron deficiency is a common cause of anaemia within this population. (Level II evidence)
2. Chronic kidney disease (CKD) patients on dialysis should have sufficient iron stores to achieve and maintain haemoglobin of 110 g/L, with iron supplements being administered to maintain the recommended targets for iron status. (Level l evidence)
3. Prior to the commencement of epoetin, adequate iron stores should be ensured. The following indices of iron stores and availability should be maintained:
   • Serum ferritin > 100 μg/L
   • Transferrin saturation (TSAT) > 20%
   • Percentage of hypochromic red cells < 10% (Level II evidence)
4. Optimisation of epoetin dose may be obtained by achieving higher target values of iron storage than the levels that define absolute or relative iron deficiency:
   • Serum ferritin 200–500 μg/L
   • TSAT 30–40%
   • Percentage of hypochromic red cells < 2.5% (Level II evidence)

Suggestions for Clinical Care

(Suggestions are based on Level III and IV sources)

• Assessment of iron prior to and after commencement of synthetic erythropoietic stimulating proteins (referred to as epoetin):
  1. During the induction phase of epoetin therapy, there is a risk of developing functional iron deficiency in patients who had adequate iron stores (as defined above) at the beginning of treatment. Prescribers must be aware of this phenomenon and be willing to prescribe additional intravenous iron to overcome this barrier to epoetin resistance. (Level III evidence)
  2. In patients in whom serum ferritin is > 500 μg/L (or TSAT > 40%), intravenous iron should be withheld for up to 3 months as long as there are no signs of functional iron deficiency (percentage of hypochromic red cells > 10%), at which time the iron parameters should be re-measured before intravenous iron is resumed. (Level III evidence)
  3. When the serum ferritin has declined to < 500 μg/L (or TSAT < 40%) and/or the percentage of hypochromic red cells has increased to > 10%, intravenous iron can be resumed at a dose reduced by one half. (Level III evidence)
• Monitoring iron levels:
  1. Dialysis patients with stable haemoglobin not treated with epoetin, with ferritin > 100 μg/L and TSAT > 20%: three-monthly. (Level IV evidence)
  2. At initiation of epoetin therapy or during period of increased epoetin dose, whether or not intravenous iron is being given: monthly. (Level IV evidence)
  3. Following attainment of target haemoglobin: three-monthly. (Level IV evidence)
  4. Measurement of iron stores must be deferred for 1 week following an intravenous iron dose of < 200 mg iron polymaltose, or for two weeks if larger dosages are used (> 200 mg iron polymaltose). (Level IV evidence)
• Administration of iron:
  1. Supplementary iron should be administered to prevent iron deficiency and to maintain adequate iron stores, so that dialysis patients can achieve and maintain a haemoglobin concentration > 110 g/L, with or without epoetin therapy. (Level II evidence)
  2. Most patients will benefit from supplementary iron, especially during the correction phase of anaemia management. IV iron is the preferred route of administration as oral iron is poorly absorbed.
  3. Most patients in whom the serum ferritin concentration is > 500 μg/L, TSAT is > 30% and percentage of hypochromic red cells < 10% will achieve or exceed a haemoglobin concentration of 110 g/L with supplementary epoetin (note: TSAT is percentage of transferrin saturated with iron). (Level II evidence)
• The current Australian Medicare schedule benefit for iron monitoring can be requested as 'iron studies', (which includes percentage transferrin saturation and ferritin) or ferritin by itself. The increased cost of requesting iron studies is justified, so as to allow a broader assessment of iron status. The costs (2005) are $36.50 (iron studies) vs. $23.95 (ferritin) respectively.
• Haemodialysis (HD) units must be aware of possible variations in routine "monthly" blood testing, e.g., after the long break vs. midweek, as this may impact on the timing of measurement of iron status with respect to IV iron dosing.
• Achieving a target ferritin of 200–500 μg/L for the population will ensure that the majority of patients will have a ferritin > 100 μg/L.
• Following on from the revised European Best Practice Guidelines, being a reasonable compromise between possible enhancements of epoetin activity vs. the risks of iron overload, the suggested upper limit for ferritin is 800 μg/L. In a similar vein, without data support, IV iron should be withheld during concurrent bacterial infections.

Haemodialysis

• There is no indication for oral iron in HD patients. Supplementary iron should be administered intravenously.
• Most patients on HD will require repetitive dosing of intravenous iron to achieve and maintain a haemoglobin concentration > 110 g/L. Intravenous iron (iron polymaltose) can be administered as either a 100 mg dose/week or as a 500–1000 mg bolus dose.

Peritoneal Dialysis

• Peritoneal dialysis (PD) patients can be given oral iron in the form of ferrous salts at a daily dose of 100–200 mg of elemental iron. Optimum absorption will occur if it is prescribed as a single dose at night without concomitant food or other medicines.
• Some PD patients, particularly if they are receiving epoetin, will not be able to maintain adequate iron stores with oral iron. Because of ease of administration, bolus dosages of intravenous iron are often prescribed. Intravenous iron should be administered slowly using veins that will not be used for HD vascular access.
• In the maintenance phase, oral iron can on occasion, sustain adequate iron stores to allow erythropoiesis to continue efficiently.

Definitions:

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Roger S. Iron. Nephrology 2006 Apr;11(S1):S217-29.



• Roger S. Iron. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Aug. 24 p. [58 references]

Not applicable: The guideline was not adapted from another source.

2006 Apr

Caring for Australasians with Renal Impairment - Disease Specific Society

Industry-sponsored funding administered through Kidney Health Australia

Not stated

Author: Simon Roger

All guideline writers are required to fill out a declaration of conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on June 5, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.