NN&I - April 2010
Patient Management 34 Nephrology News & Issues April 2010www.nephronline.com in survival among those with serum ferritin levels >1000 ng/mL versus those with levels ranging between 300 ng/mL and 1000 ng/mL (see Figure 3B).15SummaryAt our institution, lessons learned from DRIVE were applied to the anemia management program in our hemodi-alysis facilities. A retrospective multi-center analysis was conducted over a 12-month period in 2007 and over a sec-ond 12-month period in 2008. In 2007, IV iron sucrose was administered as either repletion therapy or as part of a regular low-dose regimen. Iron sucrose was withheld at a serum ferritin level of >800 ng/mL. In contrast, in 2008, IV fer -ric gluconate was administered as part of a regular low-dose regimen at a dose of 62.5 mg/week and was withheld at a higher serum ferritin cutoff of >1,200 ng/mL. Our findings demonstrated that smaller and more frequent iron dos -ing resulted in an overall reduction in total iron utilization. In addition, most patients maintained a target Hb level between 10 g/dL and 12 g/dL, while experiencing a reduction in ESA doses when regular, low-dose IV ferric glucon-ate was administered within the serum ferritin range of 200 ng/mL to 1,200 ng/ mL. There is a misconception that iron supplementation during ESA therapy may be less effective in patients with high serum ferritin values. Our study provides evidence that regular, low-dose IV iron therapy effectively keeps patients within target Hb ranges while ensuring that they are iron replete and that, consistent with the DRIVE find-ings, these goals can be achieved in the context of a higher serum ferritin cutoff. In light of the acknowledged limitations of serum ferritin when used as a marker of iron status in hemodi-alysis patients, our findings, together with those of DRIVE, indicate that deci-sions to treat with IV iron should not be based solely on serum ferritin levels. Although our study was not designed to determine the effects of these serum ferritin levels on safety outcomes or markers of inflammation, the DRIVE studies suggested that neither of these outcomes would be adversely impacted by the use of a serum ferritin cutoff of 1,200 ng/mL.6,7Our study also showed that target Hb levels can be achieved while reducing ESA requirements, which suggests that regular, low-dose IV iron use can help overcome ESA hyporesponsiveness and perhaps reduce costs associated with ESA use. This is an important con-sideration, given the potential health risks associated with ESA use and the increasing pressures placed on hemodi-alysis facilities to reduce overall costs of treatment. Prospective analyses, as well as additional, larger-scale retrospective studies, should be performed to further explore these findings. References1. National Kidney Foundation. KDOQI clinical prac-tice guidelines and clinical practice recommenda-tions for anemia in chronic kidney disease. Am J Kidney Dis. 2006;47(Suppl 3):S11-S145 2. Fishbane S, Frei GL, Maesaka J. Reduction in recombinant human erythropoietin doses by the use of chronic intravenous iron supplementation. Am J Kidney Dis. 1995;269:41-46 3. Fudin R, Jaichenko J, Shostak A, et al. Correction of uremic iron deficiency in hemodialyzed patients: a prospective study. Nephron. 1998;79:299-305 4. Macdougall IC, Tucker B, Thompson J, et al. A randomized controlled study of iron supple-mentation in patients treated with erythropoietin. Kidney Int. 1996;50:1694-1699 5. Macdougall IC. Strategies for iron supple-mentation: oral versus intravenous. Kidney Int. 1999;69(suppl):S61-S66 6. Kapoian T, O'Mara NB, Singh AK, et al. Ferric gluconate reduces Epoetin requirements in hemo-dialysis patients with elevated ferritin ferritin. J Am Soc Nephrol. 2008;19:372-379 7. Coyne DW, Kapoian T, Suki W, et al. Ferric glu-conate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low trans-ferrin saturation: results of the Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) Study. J Am Soc Nephrol. 2007;18:975-984 8. Pizzi LT, Bunz TJ, Coyne DW, et al. Ferric glucon- ate treatment provides cost savings in patients with high ferritin and low transferrin saturation. Kidney Int. 2008;74:1588-1595 9. National Kidney Foundation. KDOQI clinical prac-tice guideline and clinical practice recommenda-tions for anemia in chronic kidney disease: 2007 update of hemoglobin target. Am J Kidney Dis. 2007;50:471-530 10. Singh AK, Coyne DW, Shapiro W, et al. Predictors of the response to treatment in anemic hemodialy-sis patients with high serum ferritin and low trans-ferrin saturation. Kidney Int. 2007;71:1163-1171. 11. Kalantar-Zadeh K, Rodriguez RA, Humphreys MH. Association between serum ferritin and measures of inflammation, nutrition and iron in haemodialysis patients. Nephrol Dial Transplant. 2004;19:141-149 12. Kalantar-Zadeh K, Lee GH, Miller JE, et al. Predictors of hyporesponsiveness to erythropoi-esis-stimulating agents in hemodialysis patients. Am J Kidney Dis. 2009;53:823-834 13. Ford BA, Coyne DW, Eby CS, et al. Variability of ferritin measurements in chronic kidney disease: Implications for iron management. Kidney Int . 2009;75:104-110 14. Fishbane S. Upper limit of serum ferritin: misin-terpretation of the 2006 KDOQI anemia guidelines. Semin Dial. 2008;21:217-220 15. Pollack VE, Lorch JA, Shukla R, et al. The importance of iron in long-term survival of mainte-nance hemodialysis patients treated with epoetin-alfa and intravenous iron: analysis of 9.5 years of prospectively collected data. BMC Nephrology. 2009;10:1-12 16. Besarab A, Frinak S, Yee J. An indistinct Patient Management_0410_7.indd 34 3/18/10 3:47:54 PM
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