Managing Iron Deficiency in End-Stage Renal Disease
How do you manage iron deficiency anemia in end-stage renal disease patients? Do you advocate oral therapy and, if so, for how long before switching over to IV iron?

R. Dwarakanathan, MD, DM

Iron deficiency anemia can develop relatively early in the course of chronic renal failure. The clinical practice guidelines for the treatment of anemia in chronic renal failure, established in the United States by the National Kidney Foundation-Dialysis Outcomes Quality Initiative and in Canada by the Canadian Society of Nephrology, recommend the use of intravenous (IV) iron therapy for iron supplementation in hemodialysis patients, most patients on peritoneal dialysis, and some predialysis patients once the patient's serum ferritin falls below 100 ng/mL or transferrin saturation below 20%. Furthermore, effective iron replacement and maintenance play a vital role in efficient use of recombinant erythropoietin.

For hemodialysis patients, IV iron has proven convenient, and such patients may require supplementation with parenteral iron in excess of 1000 mg to achieve optimal response in hemoglobin/hematocrit (Hgb/Hct) levels. With regard to oral iron, patient compliance has been hindered by patient discomfort when taking such medication. However, patients on peritoneal dialysis and those with chronic kidney disease remain good candidates for oral iron because of convenience. Some authors doubt the effectiveness of oral iron replacement, as absorption may be reduced in the uremic state especially in those patients taking concomitant phosphate binders. The proof is in the pudding, however, and therefore response to iron therapy should be monitored regularly. If the ferritin and transferrin saturation does not improve to the recommended level, then supplemental intravenous iron should be used.