Anemia management

in Haemodialyis
patients

Life cycle of RBCs

Anemia-definition
Males:
Hb < 13.5 g/dL in
Females:
Hb < 12.0 g/dL in

The Kidney Disease Outcomes Quality Initiative (KDOQI) (200

Anemia in CKD-Causes
Erythropoietin deficiency
Iron deficiency
RBC life span is shortened(40% to 60% of
normal)
Haemolysis
Blood loss related to access and dialysis

Anemia in CKD-Causes

Inadequate dialysis

Hyperparathyroidism

Vitamin B12 or folate deficiency

Chronic infection or inflammation

Why anemia treatment is important ?

Fatigue and impaired cognition

Increases hospitalization

Increases mortality

Left Ventricular Hypertrophy

When to work up anaemia in CKD

patients?
Males and for post menopausal women
Haemoglobin

< 12gms%, Haematocrit < 36%

Pre menopausal women and Adolescents

Haemoglobin

< 11gms%, Haematocrit < 33%

patients on haemodialysis haemoglobin concentration to be

measured from pre-dialysis sample

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Anaemia Evaluation
Hb concentration
RBC indices / Peripheral smear /
Reticulocyte count
Tranferrin saturation
Stool occult blood
Stool parasite test

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Anaemia Evaluation

Iron / TIBC / Ferritin

Serum B12 and red cell folate concentrations
Differential white blood count
Tests for haemolysis (hapatoglobin, LDH)
Serum and / or urine protein electrophoresis
Bone marrow examination in selected cases

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Anaemia Evaluation
Assessment of occult gastrointestinal
blood loss
Intact PTH
Chronic Infections
Serum Aluminium
adequacy of dialysis to be assessed

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Iron deficiency
True iron deficiency:
caused by blood loss and/or not receiving
enough iron.
Lab values: Tsat < 20 and ferritin < 200.
Functional iron deficiency:
Not enough iron is delivered to the marrow.
Lab values: falling Tsat and rising ferritin.

KDOQI (2006) targets for

patients on dialysis

Transferrin saturation (Tsat) > 20%, no

upper limit specified

Ferritin lower limit > 200 ng/mL.

Ferritin>500 ng/ml not routinely
recommended.

Treatment of Anemia with Iron

IV administration of iron is an optimum

route of delivery of iron in HD patients

Oral iron is poorly absorbed.

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

IV Iron dose
To correct iron deficiency:
1 gram IV iron in divided doses
100 mg doses of iron sucrose injection on 10 consecutive
dialysis sessions
Reassess iron status and repeat if necessary.
Maintenance Treatment:
Smaller doses administered at regular intervals to maintain
iron status within target.
The average IV iron dose needed to maintain a stable ferritin
level appears to be in the range of 22 to 65 mg/week.

History of IV iron in renal anemia

The regular use of colloidal IV iron preparations

in the treatment of the anemia of ESRD
patients on maintenance hemodialysis was first
reported in 1967
After the beginning of the erythropoietin era, IV
iron was continued
1993 very low erythropoietin requirements in a
series of patients on maintenance hemodialysis
was reported with use of IV iron
Iron sucrose was approved for use by the US
FDA in November 2000

Shaldon S. The use of IV iron in the treatment of anaemia of ESRD patients on maintenance haemodialysis: an historical and personal view.
Nephrol Dial Transplant (2007) 22: 2325.

Problems in anemia
management in CKD

Common challenges faced are

Maintenance of stable hemoglobin levels in their

patients
Avoid overshooting Hb targets
Balance intravenous iron & EPO
Improve EPO response to use the lowest effective
EPO dose

A major concern is EPO hyporesponsiveness &

insufficient iron replacement
IV iron is important in managing these
challenges to a large extent

Kapoian T. Challenge of effectively using erythropoiesis-stimulating agents and intravenous iron. Am J Kidney Dis. 2008 Dec;52(6 Suppl):S21-8.

IV iron in CKD

IV iron therapy is superior to oral iron

supplementation in CKD
Risk factors associated with IV iron therapy
include acute allergic reactions as well as longterm complications caused by the generation of
powerful oxidant species, initiation and
propagation of lipid peroxidation
Allergy is to related to dextran moiety
Iron dextran is associated with higher incidence
of Type I hypersensitivity than Iron sucrose
Iron sucrose carries the lowest risk for
hypersensitivity

1. Horl WH. Iron therapy for renal anemia: how much needed, how much harmful? Pediatr Nephrol 2007;22:4809.

Iron sucrose in kidney disease

Iron deficiency may be corrected by oral iron

supplementation but it is limited by

Poor compliance
Adverse gastrointestinal reactions

IV iron preparations commonly used include

iron sucrose, sodium ferric gluconate, & iron
dextran
Iron sucrose is safer than iron dextran, is
generally considered a safe and effective IV
iron preparation in renal anemia

1. Li H. Intravenous iron sucrose in peritoneal dialysis patients with renal anemia. Peritoneal Dialysis International 2008;28:14954.

Iron sucrose in kidney disease

Iron sucrose is a novel and effective addition in

the management of Anemia related to kidney
diseases

Iron Sucrose is elemental iron which replenishes

body iron stores in patients with iron deficiency

Approximately 25% of hemodialysis patients can

be maintained on oral iron supplementation; the
others require IV iron supplementation

1. Dennis J. Cada. Iron Sucrose Injection. Drug Reviews From The Formulary, Volume 36, April 2001,404-412
2. W.H. Horl, OPTA-therapy with iron and erythropoiesis-stimulating agents in chronic kidney disease, nephrology dial transplant. 2007 suppl 3;iii2-iii6

Indications

IV iron sucrose is indicated in

Non-Dialysis Dependent - Chronic Kidney Disease (NDDCKD) patients receiving an erythropoietin

Non-Dialysis Dependent - Chronic Kidney Disease (NDDCKD) patients not receiving an erythropoietin
Hemodialysis Dependent - Chronic Kidney Disease (HDDCKD) patients receiving an erythropoietin
Peritoneal Dialysis Dependent - Chronic Kidney Disease
(PDD-CKD) patients receiving an erythropoietin

1. Venofer [package insert]. Shirley, NY: American Regent, Inc.; 2007.

2. Hollands JM et al. Safety of High-Dose Iron Sucrose Infusion in Hospitalized Patients With Chronic Kidney Disease. Am J Health-Syst Pharm. 2006;63(8):731-734.
3. Mircescu G et al. Intravenous iron supplementation for the treatment of anaemia in pre-dialyzed chronic renal failure patients. Nephrol Dial Transplant 2006;21:120-4.

Iron sucrose in pre-dialysis

CRF patients

Patients undergoing chronic hemodialysis often

present with anemia
IV iron therapy is administered in conjunction
with EPO as it helps prevent EPO-hyporesponsiveness
Study evaluated use of Iron sucrose in pre
dialyzed patients of CRF
60 non-diabetic CRF patients were included in
the study

Mircescu G ,et al. Intravenous iron supplementation for the treatment of anaemia in pre-dialyzed chronic renal failure patients. Nephrol Dial
Transplant 2006;21:120-4.

Results

60 patients included in the study

58% of patients reporting a rise in Hb > 1 g/dL vs. baseline in the study
80% of patients had a Hb > 10 g/dL vs. 44% at baseline
55% had a Hb > 11 g/dL vs. 0% at baseline
Mean serum iron concentration increased from

73.9 g/dL at baseline

84.2 g/dL at 6 months
101.8 g/dL at 12 months of therapy

No worsening of renal function, and no adverse events were reported

M ean serum Fe C onc.

Serum Iron concentration

110
100
90
80
70
60
50
40
30
20
10
0

Mean Serum Fe concentration

Baseline

6 months

12 months

Time line

Mircescu G et al. Intravenous iron supplementation for the treatment of anaemia in pre-dialyzed chronic renal failure patients. Nephrol Dial
Transplant 2006;21:120-4.

Efficacy of Iron sucrose in

hemodialysis patients

Schiesser et al conducted a prospective

multicentre clinical trial in 50 iron-replete
hemodialysis patients to evaluate the efficacy
of iron sucrose administration for 6 months
Hb level remained stable (121.1 at baseline &
12.11.5 g/dl at the end of the study)
Reduced dose for EPO

Schiesser et al. Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin requirement in ironreplete haemodialysis patients. Nephrol Dial Transplant (2006) 21: 28415.

Results of Schiesser et al study

Hb level remained stable (121.1 at baseline &

12.11.5 g/dl at the end of the study)
Red cell parameters remained stable

Schiesser et al. Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin requirement in iron-replete
haemodialysis patients. Nephrol Dial Transplant (2006) 21: 28415.

Iron sucrose IV reduces EPO

demand in dialysis patients

In the study of Iron sucrose in hemodialysis patients

conducted by Schiesser et al the dosage for the three
different epoetins decreased by
38.5% with darbepoetin alfa
6.3% with epoetin alfa
8.3% with epoetin beta

Schiesser et al. Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin requirement
in iron-replete haemodialysis patients. Nephrol Dial Transplant (2006) 21: 28415.

Results showing reduced EPO

need with iron sucrose

Schiesser et al showed reduced EPO need with

low dose maintenance iron sucrose in their
study

Schiesser et al. Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin requirement in iron-replete
haemodialysis patients. Nephrol Dial Transplant (2006) 21: 28415.

IV iron reduces EPO demand in

dialysis patients

Chang et al studies the beneficial effects of 2

weekly IV iron supplementation compared to once
monthly IV iron in 149 iron replete patients
EPO requirement reduced by 25% when sereum
ferritin & Transferrin saturation was maintained at
high levels by administering 2 weekly IV iron
compared to IV iron given once monthly
Significant decrease in serum albumin, cholesterol
& pre-dialysis creatinine when IV iron was
administered 2 weekly for 1 year

Chang CH et al. Reduction in erythropoietin doses by the use of chronic intravenous iron supplementation in
iron-replete hemodialysis patients. Clin Nephrol. 2002;57:136-41.

IV iron reduces EPO demand in dialysis patients

Results from Meta analysis
Compared to oral iron IV iron preparations significantly
reduce the EPO requirement in dialysis patients

Rozen-Zvi et al. Intravenous Versus Oral Iron Supplementation for the Treatment of Anemia in CKD: Systematic Review and Meta-analysis. American Journal of Kidney Diseases
2008;52:897-906.

Iron sucrose in CKD patients

not on dialysis

Charytan et al compared oral iron with Iron

sucrose in 96 NDD-CKD patients
More IV iron patients (54.2%) attained
hemoglobin values > 11.0 g/dl compared to oral
iron patients (31.3%)
There were no serious side effects with iron
sucrose

Charytan C et al. Comparison of intravenous iron sucrose to oral iron in the treatment of anemic patients with chronic kidney
disease not on dialysis. Nephron Clin Pract. 2005;100(3):c55-62.

Efficacy & safety of Iron sucrose

in peritoneal dialysis patients

Li et al conducted a study to compare the clinical

outcomes & safety of IV iron sucrose & oral ferrous
succinate in combination with rHuEPO therapy in
patients on maintenance PD
46 patients were included 26 received iron sucrose &
20 oral iron
Hb & Hct increased significantly at 2 weeks in the IV
group compared with baseline
The total response rate at 8 weeks was 94.8% for the IV
group - significantly higher than that of the oral group
(55.0%)
There were no adverse events with IV iron
8 patients in the oral group had adverse GI effects

Li H. Intravenous iron sucrose in peritoneal dialysis patients with renal anemia. Peritoneal Dialysis International 2008;28:14954.

Results of Iron sucrose in PD

patients contd.

Response rates to IV iron sucrose therapy

compared to Oral iron therapy

Li H. Intravenous iron sucrose in peritoneal dialysis patients with renal anemia. Peritoneal Dialysis International 2008;28:14954.

Efficacy of Iron sucrose in

ESRD

Iron sucrose in apparently iron-replete patients

will decrease the EPO requirements for a given
target hematocrit in patients on maintenance
hemodialysis with end-stage renal disease
(ESRD)

1. Schiesser et al. Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin
requirement in iron-replete haemodialysis patients. Nephrol Dial Transplant (2006) 21: 28412845.
2. Shaldon S. The use of IV iron in the treatment of anaemia of ESRD patients on maintenance haemodialysis: an historical and
personal view. Nephrol Dial Transplant (2007) 22: 2325.

Safety of Iron sucrose

Aronoff et al studied the safety of iron sucrose in

hemodialysis patients
665 hemodialysis patients with 80 who had
experienced previous intolerance to other IV iron
preparations were given iron sucrose
There were no serious or life-threatening drugrelated adverse events

Aronoff GR et al. Iron sucrose in hemodialysis patients: Safety of replacement and maintenance regimens. Kidney International,
2004;66:11938.

Iron sucrose in patients

hypersensitive to iron dextran

Iron dextran has been the only available

parenteral iron preparation for a long time
Its use has been associated with increased
risk of allergic reactions, even after reactionfree previous use

Haddad A et al. Use of Iron Sucrose in Dialysis Patients Sensitive to Iron Dextran. Saudi J Kidney Dis Transpl 2009;20(2):208-211

Iron sucrose in patients

hypersensitive to iron dextran

Of 205 patients of hemodialysis, 7.3% were

hypersensitive
Hypersensitive patients were given iron
sucrose for 8 weeks
None of them developed hypersensitivity
Mean hematocrit increased from 23.8% to
32.27%
Mean serum iron increased from 29.3 ng/dL to
76.8 ng/dL

Haddad A et al. Use of Iron Sucrose in Dialysis Patients Sensitive to Iron Dextran. Saudi J Kidney Dis Transpl 2009;20(2):208-211

Safety of Iron sucrose compared

to other iron preparations
Rates of life-threatening ADEs

2.
3.
4.

0.6 per million for iron

sucrose
0.9 per million for sodium
ferric gluconate complex
3.3 per million for lower
molecular weight iron dextran
11.3 per million per million for
higher molecular weight iron
dextran

Safety of Iron preparations

ADE per million

1.

12
11
10
9
8
7
6
5
4
3
2
1
0

Iron preparations

Chertow GM et al. Update on adverse drug events associated with parenteral iron. Nephrol Dial Transplant (2006) 21: 378382.

Dosing and administration

NDD-CKD - Administered as a total cumulative

dose of 1,000 mg over a 14 days as a 200 mg
slow IV injection undiluted over 2 to 5 minutes
on 5 different occasions
HDD-CKD - Administered undiluted as a 100
mg slow IV over 2 to 5 minutes or as an
infusion of 100 mg, diluted in a maximum of 100
mL of NS over 15 minutes per consecutive
hemodialysis session for a total cumulative
dose of 1,000 mg

1. Venofer [package insert]. Shirley, NY: American Regent, Inc.; 2007.

Dosing and administration contd.

PDD-CKD - Administered undiluted as a total

cumulative dose of 1,000 mg in 3 divided doses,
given by slow IV infusion, over 28 days:

2 infusions of 300 mg over 1.5 hs 14 days apart

Followed by 1 400 mg infusion over 2.5 h 14 days
later
Should be diluted in 250 mL of NS

Low maintenance doses in hemodialysis

patients include 50mg injected into the venous
limb of the haemodialysis tubing system (slow
intravenous push at a rate of 10 mg/min)

1. Venofer [package insert]. Shirley, NY: American Regent, Inc.; 2007.

Dosing and administration contd.

The usual dose is 100 mg administered one to

three times per week.
Most patients will require a minimum cumulative
dose of 1000 mg of elemental iron administered
over 10 sequential dialysis sessions to achieve a
favorable response
Patients may continue to receive IV iron therapy at
the lowest dose necessary to maintain target levels
of hemoglobin, hematocrit & iron storage
parameters

Cada DJ. Iron Sucrose Injection. Hospital Pharmacy 2001;36:40412.

Monitoring parameters

Patients receiving regular IV iron therapy require

monitoring of hematologic parameters & iron indices (Hb,
Hct, TSAT, & ferritin)
Maintain TSAT between 20% and 50%
Iron therapy should be withheld in patients with TSAT
50%
Iron therapy should be withheld in patients with ferritin
values 800 ng/mL
Since transferrin saturation values increase rapidly after
IV administration of iron sucrose, serum iron values may
be reliably obtained 48 hours after IV iron sucrose dosing

Cada DJ. Iron Sucrose Injection. Hospital Pharmacy 2001;36:40412.

Anemia management in CKD

NKF K/DOQI GUIDELINES

Both iron & EPO need to be given

Most patients need IV iron
Iron deficiency is detected when TSAT
is <20% and the serum ferritin is <100
ng/mL
Withhold IV iron if TSAT is 50% &
Ferritin is 800ng/ml

Monitoring iron stores in CKD

During initiation of EPO & increased dose:
TSAT / serum ferritin to be checked every month
in patients not receiving IV iron or once in three
months in those receiving IV iron .
Once target Hb% achieved:
Check iron stores once in 3 months
Best Practice Guidelines for management of Renal Anaemia,
Indian J Nephrol 2005;15, Supplement 1: S32-S41

When should IV iron be

discontinued?

IV iron should be discontinued when TSAT

is >50% and Ferritin is > 800ng / ml.

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Initiation of Erythropoietin
Hb <12g/dl documented 2 weeks apart
with minimum two hemoglobin
estimations.
EPO therapy should be initiated only after
correcting iron, Vitamin B12 and Folic acid
deficiency, and other possible factors
contributing to anaemia.

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Treatment with Erythropoietin

EPO should be started at a dose of 80
-120IU/Kg / week.
IV administration preferred in HD patients
Once the target Hb is achieved, Hb
monitoring should be performed once
every month

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Treatment with Erythropoietin

1gm/dl rise in Hb is necessary with EPO
therapy at the end of 2 weeks.
EPO dosage can be increased by 50% till
the target Hb is achieved.
If the rise in Hb is > 1.5Gms% at the end
of 2 weeks, the dose of EPO to be
reduced by 25%

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

KDOQI (2006) targets for

patients on dialysis

Hemoglobin (Hb) > 11 g/dL, caution when

intentionally maintaining Hb 13 g/dL.

Inadequate response to EPO

Most common causes:

iron deficiency

non-compliance to EPO therapy

Dialysis inadequacy

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Inadequate response to EPO

Other causes:
Folate or Vitamin B 12 deficiency
Chronic blood loss
Infection / inflammation (e.g., access infections, surgical
inflammation, AIDS, SLE, Occult Tuberculosis/Chronic
Malaria / Kalazar)
Malnutrition, Hemolysis, Hyperparathyroidism,
Aluminium toxicity
Haemoglobinopathies
Multiple myeloma & other malignancies. Use of ACE-1 /
ARB agents
Best Practice Guidelines for management of Renal Anaemia,
Indian J Nephrol 2005;15, Supplement 1: S32-S41

Adequacy of Dialysis

During thrice weekly maintenance

haemodialysis KT/V of >1.2 is to be
achieved to ensure optimal dialysis.

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Resistance to EPO

Failure to achieve target Hb

concentration while receiving more than
300IU/kg/week and continued need for
such dosage to maintain target in
presence of adequate iron stores and
absence of functional deficiency of iron.
Best Practice Guidelines for management of Renal Anaemia,
Indian J Nephrol 2005;15, Supplement 1: S32-S41

Pure Red Cell Aplasia

Suspect pure red cell aplasia
In patients treated with EPO > 4 weeks who develop sudden and
rapid decline in Hb concentration > 0.5 - 1 g/dl/week. Or requires
transfusion of 1 - 2 units of red cells with normal platelets and white
cell counts, in the absence of any other obvious clinical cause.
Confirmation of diagnosis
Severe non regenerative anaemia with erythroid hypoplasia of the
bone marrow and normal cellularity of the other elements.
Less than 5 % erythroblasts in the marrow with evidence of red cell
precursor block.
Demonstration of anti erythropoietin antibodies in the patients
serum.
Best Practice Guidelines for management of Renal Anaemia,
Indian J Nephrol 2005;15, Supplement 1: S32-S41

Adjuvant Therapies for

treatment of anaemia
L-carnitine
L-carnitine may enhance response to Epoetin when used as
adjuvant.
Vitamins
Oral vitamin E 1200IU given 6 hrs before a HD session along with
intensive iron may protect patients against oxidative stress related
diseases.
Hypo responsiveness to EPO therapy can be reduced by correcting
depleted vitamin C levels administered along with vitamin E

Best Practice Guidelines for management of Renal Anaemia,

Indian J Nephrol 2005;15, Supplement 1: S32-S41

Red Cell Transfusions in CKD

Transfusions should be avoided as far as possible.

Indications for transfusion are

Severely anaemic patient with recognized symptoms or
signs of anaemia. (acute blood loss with angina /
haemodynamic instability)
EPO resistant patient with chronic blood loss

If transfusion is mandatory in patients for renal

transplant, use leucocyte filters and irradiated blood.
Best Practice Guidelines for management of Renal Anaemia,
Indian J Nephrol 2005;15, Supplement 1: S32-S41

Other indications for

Iron Sucrose

Selective Use of Recombinant Human Erythropoietin in

Pregnant Patients with Severe Anemia or
Nonresponsive to Iron Sucrose Alone
Krafft A, Bencaiova G, Breymann C.
Feto-Maternal Hematology Group, Division of Obstetrics, Department of Obstetrics
and Gynecology, University Hospital Zurich, Zurich, Switzerland.

This study shows an effective treatment regimen for patients

with various degrees of anemia in pregnancy.
Iron sucrose is a safe and effective treatment option.
In cases of severe iron deficiency anemia or poor response to
parenteral iron therapy additional administration of rhEPO might
be considered.
However, the mechanism for not responding to intravenous iron
therapy despite iron deficiency anemia still remains unclear to a
large extent.
Fetal Diagn Ther 2009

Efficacy and safety of intravenously administered iron

sucrose with and without adjuvant recombinant human
erythropoietin for the treatment of resistant irondeficiency anemia during pregnancy
Breymann C, Visca E, Huch R, Huch A.
Department of Obstetrics and Gynecology, the Clinic of Obstetrics, and the
Division of Perinatal Physiology, University of Zurich, Switzerland.

Adjuvant recombinant human erythropoietin safely

enhanced the efficacy of iron sucrose in the treatment of
gestational iron-deficiency anemia resistant to orally
administered iron alone.

Am J Obstet Gynecol 2001

A randomized, double-blind, placebo controlled, multicenter study of intravenous iron sucrose and placebo in
the treatment of restless legs syndrome
Grote L, Leissner L, Hedner J, Ulfberg J.
Sleep Disorders Center, Department of Pulmonary Medicine, Sahlgrenska University Hospital,
Gothenburg, Sweden.

This study showed a lack of superiority of iron sucrose at 11

weeks but found evidence that iron sucrose reduced RLS
symptoms both in the acute phase (7 weeks) and during longterm follow up in patients with variable degree of iron
deficiency.

Further studies on target patient groups, dosing and dosing

intervals are warranted before iron sucrose could be
considered for treatment of iron deficient patients with RLS.
Moy Disord 2009 June 1

Safety and usefulness of intravenous iron sucrose in

the management of preoperative anemia in patients
with menorrhagia: a phase IV, open-label,
prospective, randomized study
Kim YH, Chung HH, Kang SB, Kim SC, Kim YT.
Department of Obstetrics and Gynecology, College of Medicine, Seoul
National University, Seoul, Korea.

Preoperative intravenous iron sucrose administration is more

effective than oral iron and is as safe as oral iron therapy in
the correction of preoperative anemia due to menorrhagia.

Acta Haematol 2009;121(1

Intravenous iron sucrose is superior to oral iron

sulphate for correcting anaemia and restoring iron
stores in IBD patients: A randomized, controlled,
evaluator-blind, multicentre study

Lindgren S, Wikman O, Befrits R, Blom H, Eriksson A, Granno C, Ung KA,

Hjortswang H, Lindgren A, Unge P.
Department of Medicine, Gastroenterology-Hepatology Division, University Hospital
MAS, Malmo.

Treatment with intravenous iron sucrose is effective, safe, well

tolerated and superior to oral iron in correcting haemoglobin
and iron stores in patients with IBD.

Scand J Gastroenterol 2009

Usefulness of the administration of intravenous

iron sucrose for the correction of preoperative
anemia in major surgery patients
Muoz M, Garca-Erce JA, Dez-Lobo AI, Campos A, Sebastianes C, Bisbe
E; Anaemia Working Group Espaa (AWGE).

Because of the low incidence of side effects and the rapid

increase of hemoglobin levels, IVIS emerges as a safe,
effective drug for treating preoperative anemia in surgery
patient populations.

Med Clin (Barc) 2009

Efficacy and safety of intravenous iron sucrose therapy

in a group of children with iron deficiency anemia
Pinsk V, Levy J, Moser A, Yerushalmi B, Kapelushnik J.
Pediatric Day Care Unit, Soroka University Medical Center, Faculty of
Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

These preliminary data suggest that administration of

intravenous iron sucrose in pediatric patients is well tolerated
and has a good clinical result, with minimal adverse reactions .

Isr Med Assoc J 2008

A 12-week randomised study comparing

intravenous iron sucrose versus oral ferrous
sulphate for treatment of postpartum anemia.
Westad S, Backe B, Salvesen KA, Nakling J, kland I, Borthen I,
Rognerud Jensen OH, Kols T, Lkvik B, Smedvig E.
Department of Obstetrics and Gynecology, Innlandet Hospital Trust,
Lillehammer, Norway. stian.westad@sykehuset-innlandet.no

Women who received 600 mg intravenous iron sucrose

followed by standard oral iron after four weeks, replenished
their iron stores more rapidly and had a more favorable
development of the fatigue score indicating improved quality of
life.

Acta Obstet Gynecol Scan

A phase III randomized controlled study comparing

iron sucrose intravenously (IV) to no iron treatment of
anemia in cancer patients undergoing chemotherapy
and erythropoietin stimulating agent (ESA) therapy
R. E. Bellet, H. Ghazal, M. Flam, A. Drelichman, N. Gabrail, D. Woytowitz, D.
Loesch, D. Niforos, A. Mangione, L. Anthony and Iron Sucrose Study Group

IV iron sucrose increased Hgb levels and iron stores

significantly and is well tolerated in doses up to 500 mg
increments in ESA treated patients with cancer chemotherapyrelated anemia.

IV iron sucrose should be considered in combination with

erythropoietic therapy in anemic cancer patients receiving
chemotherapy.
Journal of Clinical Oncolo

Summary

Iron (blood) losses are high in HD patients

Regular use of intravenous (IV) iron improves
sensitivity to Erythropoietin
maintain TSAT >20% and ferritin >200 ng/mL
Adequate and appropriate dosing of
Erythropoietin is necessary
Aim for Hemoglobin (Hb) > 11 g/dL, caution
when intentionally maintaining Hb 13 g/dL.

Key points
Anemia in CKD patients is common
EPO therapy forms the mainstay of treatment
EPO therapy alone may be ineffective unless
supplemented by iron
Oral iron supplementation has problems of
intolerance
IV iron forms the best adjunct with EPO in
CKD patients

Key points

IV iron sucrose is one of the iron preparations

It is indicated in hemodialysis patients, non
hemodialysis patients with or without EPO and
peritoneal dialysis patients
Efficacy is proved in each of these indications
Low maintenance dose of Iron sucrose keeps
Hb and Hct stable in hemodialysis patients

Key points
Iron sucrose administration along with
EPO reduces the dose requirement of
EPO
Iron sucrose can be safely given to
patients hypersensitive to iron dextran
Iron sucrose is safer than other IV iron
preparations

Thank You