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Babitt JL, Eisenga MF, Haase VH, Kshirsagar AV, Levin A, Locatelli F, Małyszko J, Swinkels DW, Tarng DC, Cheung M, Jadoul M, Winkelmayer WC, Drüeke TB. Controversies in optimal anemia management: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int 2021; 99:1280-1295. [PMID: 33839163 DOI: 10.1016/j.kint.2021.03.020] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
In chronic kidney disease, anemia and disordered iron homeostasis are prevalent and associated with significant adverse consequences. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) issued an anemia guideline for managing the diagnosis, evaluation, and treatment of anemia in chronic kidney disease. Since then, new data have accrued from basic research, epidemiological studies, and randomized trials that warrant a re-examination of previous recommendations. Therefore, in 2019, KDIGO decided to convene 2 Controversies Conferences to review the latest evidence, explore new and ongoing controversies, assess change implications for the current KDIGO anemia guideline, and propose a research agenda. The first conference, described here, focused mainly on iron-related issues, including the contribution of disordered iron homeostasis to the anemia of chronic kidney disease, diagnostic challenges, available and emerging iron therapies, treatment targets, and patient outcomes. The second conference will discuss issues more specifically related to erythropoiesis-stimulating agents, including epoetins, and hypoxia-inducible factor-prolyl hydroxylase inhibitors. Here we provide a concise overview of the consensus points and controversies resulting from the first conference and prioritize key questions that need to be answered by future research.
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Affiliation(s)
- Jodie L Babitt
- Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michele F Eisenga
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Molecular Physiology and Biophysics and Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Medical Cell Biology, Division of Integrative Physiology, Uppsala University, Uppsala, Sweden
| | - Abhijit V Kshirsagar
- UNC Kidney Center and Division of Nephrology & Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Dorine W Swinkels
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA
| | - Tilman B Drüeke
- Inserm Unit 1018, Team 5, CESP, Hôpital Paul Brousse, Paris-Sud University (UPS), Villejuif, France; Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Villejuif, France.
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52
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Wang P, Guo C, Pan H, Chen W, Peng D. Iron Sucrose: A Double-Edged Sword in High Phosphate Media-Induced Vascular Calcification. Calcif Tissue Int 2021; 108:798-807. [PMID: 33439323 DOI: 10.1007/s00223-020-00804-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
The high incidence of vascular calcification (VC) in patients with chronic kidney disease (CKD) has become an important clinical subject. Hyperphosphatemia is a primary cause of CKD-related VC. Intravenous iron sucrose (IS) is commonly used to treat anemia in CKD patients, and is effective and well tolerated worldwide. However, the interaction between iron and VC remains controversial, and the underlying mechanisms are yet to be clarified. In the present study, ex vivo normal rat aortic rings were cultured with various concentrations of phosphate and IS, and the levels of calcium and iron depositions, oxidative injury, as well as phenotypic marker genes were detected. To the best of our knowledge, the present study is the first to report that IS is a double-edged sword in high phosphate media-induced VC which not only alleviates VC in a dose-dependent manner but also leads to iron overload in vasculature when in high concentration. IS is a promising agent for VC prevention in patients with hyperphosphatemia and iron deficiency. Meanwhile, the appropriate blood concentration of IS in patients with hyperphosphatemia needs to be explored clinically.
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Affiliation(s)
- Ping Wang
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Chengkun Guo
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Hui Pan
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Wangshan Chen
- Nephrology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, China
| | - Dan Peng
- Neonatology Department, The First People's Hospital of Jingmen, Jingmen, 448000, Hubei, People's Republic of China.
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53
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Cirillo L, Somma C, Allinovi M, Bagalà A, Ferro G, Di Marcantonio E, Bellelli S, Dallari LA, Ballo P, Dattolo PC. Ferric carboxymaltose vs. ferrous sulfate for the treatment of anemia in advanced chronic kidney disease: an observational retrospective study and cost analysis. Sci Rep 2021; 11:7463. [PMID: 33811227 PMCID: PMC8018957 DOI: 10.1038/s41598-021-86769-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 03/15/2021] [Indexed: 01/02/2023] Open
Abstract
In non-dialysis-dependent chronic kidney disease (NDD-CKD), erythropoiesis-stimulating agents (ESAs) and iron supplementation are essential for anemia management. Ferric carboxymaltose (FCM) is a relatively novel intravenous iron formulation used in different clinical settings, although scarce data exist in NDD-CKD patients. Primary objective of this study was to retrospectively evaluate the efficacy of FCM compared with oral ferrous sulfate for the treatment of iron-deficiency anemia in a cohort of NDD-CKD patients, considering also the treatment costs. This was a monocentric, retrospective observational study reviewing 349 NDD-CKD patients attending an outpatient clinic between June 2013 and December 2016. Patients were treated by either FCM intravenous infusion or oral ferrous sulfate. We collected serum values of hemoglobin, ferritin and transferrin saturation (TSAT) and ESAs doses at 12 and 18 months. The costs related to both treatments were also analysed. 239 patients were treated with FCM intravenous infusion and 110 patients with oral ferrous sulfate. The two groups were not statistically different for age, BMI and eGFR values. At 18 months, hemoglobin, serum ferritin and TSAT values increased significantly from baseline in the FCM group, compared with the ferrous sulfate group. ESAs dose and rate of infusion decreased only in the FCM group. At 18 months, the treatment costs, analysed per week, was higher in the ferrous sulfate group, compared with the FCM group, and this was mostly due to a reduction in ESAs prescription in the FCM group. Routine intravenous FCM treatment in an outpatient clinic of NDD-CKD patients results in better correction of iron-deficiency anemia when compared to ferrous sulfate. In addition to this, treating NDD-CKD patients with FCM leads to a significant reduction of the treatment costs by reducing ESAs use.
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Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Chiara Somma
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplant Unit, Careggi University Hospital, Florence, Italy
| | - Alfredo Bagalà
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Giuseppe Ferro
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Elio Di Marcantonio
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Stefania Bellelli
- Health Technology Assessment and Management (HTAM) Research Area, IRES Piemonte, Torino, Italy
| | - Lorenzo Antonio Dallari
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Claudio Dattolo
- Nephrology and Dialysis Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy.
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54
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Del Vecchio L, Ekart R, Ferro CJ, Malyszko J, Mark PB, Ortiz A, Sarafidis P, Valdivielso JM, Mallamaci F. Intravenous iron therapy and the cardiovascular system: risks and benefits. Clin Kidney J 2021; 14:1067-1076. [PMID: 34188903 PMCID: PMC8223589 DOI: 10.1093/ckj/sfaa212] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Anaemia is a common complication of chronic kidney disease (CKD). In this setting, iron deficiency is frequent because of the combination of increased iron needs to sustain erythropoiesis with increased iron losses. Over the years, evidence has accumulated on the involvement of iron in influencing pulmonary vascular resistance, endothelial function, atherosclerosis progression and infection risk. For decades, iron therapy has been the mainstay of therapy for renal anaemia together with erythropoiesis-stimulating agents (ESAs). Despite its long-standing use, grey areas still surround the use of iron therapy in CKD. In particular, the right balance between either iron repletion with adequate therapy and the avoidance of iron overload and its possible negative effects is still a matter of debate. This is particularly true in patients having functional iron deficiency. The recent Proactive IV Iron Therapy in Haemodialysis Patients trial supports the use of intravenous (IV) iron therapy until a ferritin upper limit of 700 ng/mL is reached in haemodialysis patients on ESA therapy, with short dialysis vintage and minimal signs of inflammation. IV iron therapy has also been proven to be effective in the setting of heart failure (HF), where it improves exercise capacity and quality of life and possibly reduces the risk of HF hospitalizations and cardiovascular deaths. In this review we discuss the risks of functional iron deficiency and the possible benefits and risks of iron therapy for the cardiovascular system in the light of old and new evidence.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, Como, Italy
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Clinical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Renal Unit, University Hospitals Birmingham and Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group and UDETMA, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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55
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Benson CS, Shah A, Stanworth SJ, Frise CJ, Spiby H, Lax SJ, Murray J, Klein AA. The effect of iron deficiency and anaemia on women's health. Anaesthesia 2021; 76 Suppl 4:84-95. [PMID: 33682105 DOI: 10.1111/anae.15405] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/14/2022]
Abstract
Iron deficiency and anaemia are global health problems and major causes of morbidity in women. Current definitions of anaemia in women are historic and have been challenged by recent data from observational studies. Menstrual loss, abnormal uterine bleeding and pregnancy put women at risk of developing iron deficiency which can result in severe fatigue, reduced exercise capacity and poor work performance. Iron deficiency and anaemia during pregnancy are associated with adverse maternal and fetal outcomes, including neurocognitive deficits in children born to iron-deficient mothers. Both iron deficiency and anaemia are common in women undergoing surgery but their association with poor outcomes remains uncertain. The enduring burden of iron deficiency and anaemia in women suggests that current strategies for recognition, prevention and treatment are limited in their utility. Improvements in our understanding of iron homeostasis and the development of new iron preparations, which are better absorbed with fewer side-effects, may improve therapeutic effectiveness of oral iron. Intravenous iron is efficacious for correcting anaemia rapidly but high-quality data on patient-centred outcomes and cost-effectiveness are currently lacking. Many recommendations for the treatment of iron deficiency and anaemia in national guidelines are not supported by high-quality evidence. There is a need for robust epidemiological data and well-designed clinical trials. The latter will require collaborative working between researchers and patients to design studies in ways that incorporate patients' perspectives on the research process and target outcomes that matter to them.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- NIHR Oxford Biomedical Research Centre, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NHS Blood and Transplant, Oxford, UK.,Fetal Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C J Frise
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK.,School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - S J Lax
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - J Murray
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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56
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Fishbane S, El-Shahawy MA, Pecoits-Filho R, Van BP, Houser MT, Frison L, Little DJ, Guzman NJ, Pergola PE. Roxadustat for Treating Anemia in Patients with CKD Not on Dialysis: Results from a Randomized Phase 3 Study. J Am Soc Nephrol 2021; 32:737-755. [PMID: 33568383 PMCID: PMC7920165 DOI: 10.1681/asn.2020081150] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Current anemia therapies for patients with non-dialysis-dependent CKD may require injection and medical visits. Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, stimulates erythropoiesis and improves iron homeostasis. METHODS In this double-blind phase 3 study, we randomized patients with non-dialysis-dependent CKD stages 3-5 and hemoglobin <10.0 g/dl (1:1) to thrice-weekly 70-mg oral roxadustat or placebo. Doses were titrated throughout the study based on hemoglobin levels. The primary efficacy end point was mean change from baseline in hemoglobin averaged over weeks 28-52 versus placebo, irrespective of rescue therapy use. We assessed patients for adverse events. RESULTS The study included 2781 patients, 1393 who received roxadustat and 1388 who received placebo. Mean baseline hemoglobin was 9.1 g/dl for both groups. The mean change in hemoglobin from baseline was 1.75 g/dl (95% confidence interval [95% CI], 1.68 to 1.81) with roxadustat versus 0.40 g/dl (95% CI, 0.33 to 0.47) with placebo, (P<0.001). Among 411 patients with baseline elevated high-sensitivity C-reactive protein, mean change in hemoglobin from baseline was 1.75 g/dl (95% CI, 1.58 to 1.92) with roxadustat versus 0.62 g/dl (95% CI, 0.44 to 0.80) with placebo, (P<0.001). Roxadustat reduced the risk of red blood cell transfusion by 63% (hazard ratio, 0.37; 95% CI, 0.30 to 0.44). The most common adverse events with roxadustat and placebo, respectively, were ESKD (21.0% versus 20.5%), urinary tract infection (12.8% versus 8.0%), pneumonia (11.9% versus 9.4%), and hypertension (11.5% versus 9.1%). CONCLUSIONS Roxadustat effectively increased hemoglobin in patients with non-dialysis-dependent CKD and reduced the need for red blood cell transfusion, with an adverse event profile comparable to that of placebo. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Safety and Efficacy Study of Roxadustat to Treat Anemia in Patients With CKD, Not on Dialysis, NCT02174627.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, New York
| | - Mohamed A. El-Shahawy
- Department of Medicine, Keck-University of Southern California School of Medicine, Los Angeles, California
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifical Catholic University of Parana, Curitiba, Brazil,Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Bui Pham Van
- Department of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Mark T. Houser
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
| | - Lars Frison
- Biostatistics, Biopharmaceuticals Research & Development, AstraZeneca Gothenburg, Mölndal, Sweden
| | - Dustin J. Little
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
| | - Nicolas J. Guzman
- Global Medicines Development, Biopharmaceuticals Research & Development, AstraZeneca Gaithersburg, Gaithersburg, Maryland
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Cases A, Puchades MJ, de Sequera P, Quiroga B, Martin-Rodriguez L, Gorriz JL, Portolés J. Iron replacement therapy in the management of anaemia in non-dialysis Chronic kidney disease patients: Perspective of the Spanish Nephrology Society Anaemia Group. Nefrologia 2021; 41:123-136. [PMID: 36166211 DOI: 10.1016/j.nefroe.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/14/2020] [Indexed: 06/16/2023] Open
Abstract
This work presents an update on the management of iron deficiency in patients with chronic kidney disease (CKD), either with or without anaemia. A review is made of the recommendations of the guidelines for the treatment of iron deficiency in CKD. It also presents new studies on iron deficiency in patients with CKD, as well as new findings about iron therapy and its impact on clinical outcomes. Anaemia is a common complication of CRF, and is associated with a decrease in the quality of life of the patients, as well as an increase in morbidity and mortality. Iron deficiency (absolute or functional) is common in non-dialysis chronic kidney disease patients, and may cause anaemia or a low response to erythropoiesis-stimulating agents. For this reason, the clinical guidelines for the treatment of the anaemia in Nephrology indicate the correction of the deficiency in the presence of anaemia. Iron replacement therapy is indicated in patients with CKD and anaemia (Hb < 12 g/dl) in accordance with the guidelines. There is no unanimity in the indication of iron replacement therapy in patients with Hb > 12 g/dl, regardless of whether they have an absolute or functional iron deficiency. Intravenous iron replacement therapy is safe, more efficient and rapid than oral therapy for achieving an increase haemoglobin lels and reducing the dose of erythropoiesis-stimulating agents. For the administration of intravenous iron in non-dialysis chronic renal failure patients a strategy of high doses and low frequency would be preferred on being more convenient for the patient, preserves better the venous capital, and is safe and cost-effective. Iron plays an essential role in energy metabolism and other body functions beyond the synthesis of haemoglobin, for which the iron deficiency, even in the absence of anaemia, could have harmful effects in patients with CKD. The correction of the iron deficiency, in the absence of anaemia is associated with functional improvement in patients with heart failure, and in muscle function or fatigue in patients without CKD. Despite the evidence of benefits in the correction of iron deficiency in patients with CKD, more studies are required to evaluate the impact of the correction of the iron deficiency in the absence of anaemia on morbidity and mortality, quality of life and physical capacity, as well as the long-term effect of oral and intravenous iron replacement therapy in this population.
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Affiliation(s)
| | - Maria Jesús Puchades
- Servicio de Nefrología, Hospital Clínico, INCLIVA, Universidad de Valencia, Valencia, Spain
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Borja Quiroga
- Servicio de Nefrología, Hospital Universitario de la Princesa, Madrid, Servicio de Nefrología, Hospital Clínico, Valencia, INCLIVA, Universidad de Valencia, Spain
| | - Leyre Martin-Rodriguez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro Majadahonda, REDInREN ISCiii 016/009/009 RETYC, Majadahonda, Madrid, Spain
| | - José Luis Gorriz
- Servicio de Nefrología, Hospital Clínico, INCLIVA, Universidad de Valencia, Valencia, Spain.
| | - José Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro Majadahonda, REDInREN ISCiii 016/009/009 RETYC, Majadahonda, Madrid, Spain
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58
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Luo Q, Lao C, Huang C, Xia Y, Ma W, Liu W, Chen Z. Iron Overload Resulting from the Chronic Oral Administration of Ferric Citrate Impairs Intestinal Immune and Barrier in Mice. Biol Trace Elem Res 2021; 199:1027-1036. [PMID: 32468223 DOI: 10.1007/s12011-020-02218-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/22/2020] [Indexed: 01/15/2023]
Abstract
Ferric citrate (FC) is an iron-containing phosphate binder used as a food additive for iron supplementation. To explore the potential effect of ferric citrate on intestinal epithelial function, in the present study, we administered the mice orally for 16 weeks with different doses of iron citrate (2.5 mg/day (1.25%), 5 mg/day (2.5%), and 10 mg/day (5.0%)). We found that the iron levels of serum and tissue significantly increased, which caused the body to be in an iron overload state; meanwhile, the villus height, the ratio of villus height to crypt depth, and the number of intraepithelial lymphocytes and goblet cells in jejunum all decreased. Iron overload upregulated the pro-inflammatory cytokines (IL-1β, IL-2, IL-6, TNF-ɑ), while downregulated the anti-inflammatory cytokines (IL-4, IL-10) and sIgA. Moreover, iron overload increased serum D-lactate (D-LA) levels and decreased tight junction proteins (claudin-1, occludin, and ZO-1), MUC-2, and TFF3. In addition, iron overload upregulated the content of MDA and protein carbonyl, while downregulated the activity and content of T-AOC, GSH-PX, SOD, CAT, and GSH. To sum up, the present results showed that long-term oral administration of FC resulted in iron overload, which consequently impaired intestinal immune and barrier function in mice. Meanwhile, the effect on intestinal damage may be highly related to the increase of oxidative stress in the jejunum.
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Affiliation(s)
- Qihui Luo
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Chengjie Lao
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Chao Huang
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Yu Xia
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Wenjing Ma
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Wentao Liu
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China
| | - Zhengli Chen
- Laboratory of Experimental Animal Disease Model, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, China.
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Guedes M, Muenz D, Zee J, Lopes MB, Waechter S, Stengel B, Massy ZA, Speyer E, Ayav C, Finkelstein F, Sesso R, Pisoni RL, Robinson BM, Pecoits-Filho R. Serum biomarkers of iron stores are associated with worse physical health-related quality of life (HRQoL) in non-dialysis dependent chronic kidney disease (NDD-CKD) patients with or without anemia. Nephrol Dial Transplant 2021; 36:1694-1703. [PMID: 33624825 PMCID: PMC8396397 DOI: 10.1093/ndt/gfab050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/28/2022] Open
Abstract
Background Iron deficiency (ID) is a common condition in nondialysis-dependent chronic kidney disease (NDD-CKD) patients that is associated with poorer clinical outcomes. However, the effect of ID on health-related quality of life (HRQoL) in this population is unknown. We analyzed data from a multinational cohort of NDD-CKD Stages 3–5 patients to test the association between transferrin saturation (TSAT) index and ferritin with HRQoL. Methods Patients from Brazil (n = 205), France (n = 2015) and the USA (n = 293) in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps, 2013–2019) were included. We evaluated the association of TSAT and ferritin (and functional and absolute ID, defined as TSAT ≤20% and ferritin ≥300 or <50 ng/mL) on pre-specified HRQoL measures, including the 36-item Kidney Disease Quality of Life physical component summary (PCS) and mental component summary (MCS) as the primary outcomes. Models were adjusted for confounders including hemoglobin (Hb). Results TSAT ≤15% and ferritin <50 ng/mL and ≥300 ng/mL were associated with worse PCS scores, but not with MCS. Patients with composite TSAT ≤20% and ferritin <50 or ≥300 ng/mL had lower functional status and worse PCS scores than those with a TSAT of 20–30% and ferritin 50–299 ng/mL. Patients with a lower TSAT were less likely to perform intense physical activity. Adjustment for Hb only slightly attenuated the observed effects. Conclusions Low TSAT levels, as well as both low TSAT with low ferritin and low TSAT with high ferritin, are associated with worse physical HRQoL in NDD-CKD patients, even after accounting for Hb level. Interventional studies of iron therapy on HRQoL among NDD-CKD individuals are needed to confirm these findings.
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Affiliation(s)
- Murilo Guedes
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Daniel Muenz
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | - Bénédicte Stengel
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | - Ziad A Massy
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France.,France, Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt/Paris, France
| | - Elodie Speyer
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | - Carole Ayav
- Université Paris-Saclay, Université Versailles Saint-Quentin-en-Yvelines, Université Paris-Sud, Inserm, Équipe Epidémiologie Clinique, CESP, 94807, Villejuif, France
| | | | | | | | | | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Pontificia Universidade Catolica do Parana, Curitiba, Brazil
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ESA, Iron Therapy and New Drugs: Are There New Perspectives in the Treatment of Anaemia? J Clin Med 2021; 10:jcm10040839. [PMID: 33670704 PMCID: PMC7922992 DOI: 10.3390/jcm10040839] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023] Open
Abstract
Anemia is a well-known consequence of chronic kidney disease (CKD); it is mainly due to a relative insufficiency of erythropoietin synthesis by the failing kidneys. Over the years, the combination of erythropoiesis stimulating agents (ESA) and iron has become the standard of care of anemia. All ESAs effectively increase hemoglobin (Hb) levels in a substantial percentage of patients. However, in the last decade, their use has been surrounded by safety issues in increased cardiovascular risk, especially when used at high doses in inflamed and hyporesponsive patients. This has led to the definition of a more cautious Hb target. Iron deficiency is very frequent in CKD patients, with a higher frequency in non-dialysis patients. Traditionally, iron supplementation is mostly used as supportive therapy for anemia control. However, the concept is growing that intravenous iron therapy per se could be beneficial in the presence of heart failure. A new class of drugs, prolyl hydroxylase domain (PHD) inhibitors (PHD inhibitors) is becoming available for the treatment of anemia in CKD patients. Theoretically, these agents have a number of advantages, the main ones being that of stimulating the synthesis of endogenous erythropoietin and increasing iron availability. The impact of their future use in clinical practice is still to be defined. Another possible strategy could be targeting serum hepcidin and its related pathways. This possibility is fascinating from the scientific point of view, but at present its development phase is still far from clinical application.
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Richards T, Baikady RR, Clevenger B, Butcher A, Abeysiri S, Chau M, Swinson R, Collier T, Dodd M, Dyck LV, Macdougall I, Murphy G, Browne J, Bradbury A, Klein A. Preoperative intravenous iron for anaemia in elective major open abdominal surgery: the PREVENTT RCT. Health Technol Assess 2021; 25:1-58. [PMID: 33632377 DOI: 10.3310/hta25110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Anaemia affects 30-50% of patients before they undergo major surgery. Preoperative anaemia is associated with increased need for blood transfusion, postoperative complications and worse patient outcomes after surgery. International guidelines support the use of intravenous iron to correct anaemia in patients before surgery. However, the use of preoperative intravenous iron for patient benefit has not been assessed in the setting of a formal clinical trial. OBJECTIVES To assess if intravenous iron given to patients with anaemia before major abdominal surgery is beneficial by reducing transfusion rates, postoperative complications, hospital stay and re-admission to hospital, and improving quality of life outcomes. DESIGN A multicentre, double-blinded, randomised, controlled, Phase III clinical trial, with 1 : 1 randomisation comparing placebo (normal saline) with intravenous iron (intravenous ferric carboxymaltose 1000 mg). Randomisation and treatment allocation were by a secure web-based service. SETTING The study was conducted across 46 hospitals in England, Scotland and Wales between September 2013 and September 2018. PARTICIPANTS Patients aged > 18 years, undergoing elective major open abdominal surgery, with anaemia [Hb level of > 90 g/l and < 120 g/l (female patients) and < 130 g/l (male patients)] who could undergo randomisation and treatment 10-42 days before their operation. INTERVENTION Double-blinded study comparing placebo of normal saline with 1000 mg of ferric carboxymaltose administered 10-42 days prior to surgery. MAIN OUTCOME MEASURES Co-primary end points were risk of blood transfusion or death at 30 days postoperatively, and rate of blood transfusions at 30 days post operation. RESULTS A total of 487 patients were randomised (243 given placebo and 244 given intravenous iron), of whom 474 completed the trial and provided data for the analysis of the co-primary end points. The use of intravenous iron increased preoperative Hb levels (mean difference 4.7 g/l, 95% confidence interval 2.7 to 6.8 g/l; p < 0.0001), but had no effect compared with placebo on risk of blood transfusion or death (risk ratio 1.03, 95% confidence interval 0.78 to 1.37; p = 0.84; absolute risk difference +0.8%, 95% confidence interval -7.3% to 9.0%), or rates of blood transfusion (rate ratio 0.98, 95% confidence interval 0.68 to 1.43; p = 0.93; absolute rate difference 0.00, 95% confidence interval -0.14 to 0.15). There was no difference in postoperative complications or hospital stay. The intravenous iron group had higher Hb levels at the 8-week follow-up (difference in mean 10.7 g/l, 95% confidence interval 7.8 to 13.7 g/l; p < 0.0001). There were a total of 71 re-admissions to hospital for postoperative complications in the placebo group, compared with 38 re-admissions in the intravenous iron group (rate ratio 0.54, 95% confidence interval 0.34 to 0.85; p = 0.009). There were no differences between the groups in terms of mortality (two per group at 30 days post operation) or in any of the prespecified safety end points or serious adverse events. CONCLUSIONS In patients with anaemia prior to elective major abdominal surgery, there was no benefit from giving intravenous iron before the operation. FUTURE WORK The impact of iron repletion on recovery from postoperative anaemia, and the association with reduced re-admission to hospital for complications, should be investigated. LIMITATIONS In the preoperative intravenous iron to treat anaemia in major surgery (PREVENTT) trial, all patients included had anaemia and only 20% had their anaemia corrected before surgery. The definition and causality of iron deficiency in this setting is not clear. TRIAL REGISTRATION Current Controlled Trials ISRCTN67322816 and ClinicalTrials.gov NCT01692418. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25 No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Toby Richards
- Division of Surgery, University of Western Australia, Perth, WA, Australia.,Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | | | - Ben Clevenger
- Division of Surgery, University College London, London, UK.,Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Anna Butcher
- Division of Surgery, University College London, London, UK
| | - Sandy Abeysiri
- Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | - Marisa Chau
- Institute of Clinical Trial and Methodology, University College London, London, UK.,Division of Surgery, University College London, London, UK
| | - Rebecca Swinson
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Van Dyck
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Iain Macdougall
- Department of Renal Medicine, King's College Hospital, London, UK
| | - Gavin Murphy
- NIHR Leicester Biomedical Research Centre, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Andrew Bradbury
- University Department of Vascular Surgery (University of Birmingham), Solihull Hospital, Solihull, UK
| | - Andrew Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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A real-world longitudinal study of anemia management in non-dialysis-dependent chronic kidney disease patients: a multinational analysis of CKDopps. Sci Rep 2021; 11:1784. [PMID: 33469061 PMCID: PMC7815803 DOI: 10.1038/s41598-020-79254-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023] Open
Abstract
Previously lacking in the literature, we describe longitudinal patterns of anemia prescriptions for non-dialysis-dependent chronic kidney disease (NDD-CKD) patients under nephrologist care. We analyzed data from 2818 Stage 3-5 NDD-CKD patients from Brazil, Germany, and the US, naïve to anemia medications (oral iron, intravenous [IV] iron, or erythropoiesis stimulating agent [ESA]) at enrollment in the CKDopps. We report the cumulative incidence function (CIF) of medication initiation stratified by baseline characteristics. Even in patients with hemoglobin (Hb) < 10 g/dL, the CIF at 12 months for any anemia medication was 40%, and 28% for ESAs. Patients with TSAT < 20% had a CIF of 26% and 6% for oral and IV iron, respectively. Heart failure was associated with earlier initiation of anemia medications. IV iron was prescribed to < 10% of patients with iron deficiency. Only 40% of patients with Hb < 10 g/dL received any anemia medication within a year. Discontinuation of anemia treatment was very common. Anemia treatment is initiated in a limited number of NDD-CKD patients, even in those with guideline-based indications to treat. Hemoglobin trajectory and a history of heart failure appear to guide treatment start. These results support the concept that anemia is sub-optimally managed among NDD-CKD patients in the real-world setting.
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63
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Zheng Q, Wang Y, Yang H, Sun L, Fu X, Wei R, Liu YN, Liu WJ. Efficacy and Safety of Daprodustat for Anemia Therapy in Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 11:573645. [PMID: 33597868 PMCID: PMC7883598 DOI: 10.3389/fphar.2020.573645] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022] Open
Abstract
Objective: Daprodustat is a novel oral agent in treating anemia of chronic kidney disease (CKD), and several clinical trials have been conducted to compare daprodustat with recombinant human erythropoietin (rhEPO) or placebo. Our systematic review aimed to investigate the efficacy and safety of daprodustat for anemia treatment in both dialysis-dependent (DD) and non-dialysis-dependent (NDD) patients. Methods: Six databases were searched for randomized controlled trials (RCTs) reporting daprodustat vs. rhEPO or placebo for anemia patients in CKD. The outcome indicators were focused on hemoglobin (Hb), ferritin, transferrin saturation (TSAT), total iron-binding capacity (TIBC), vascular endothelial growth factor (VEGF), and serious adverse events (SAEs). Results: Eight eligible studies with 1,516 participants were included. For both NDD and DD patients, changes in Hb levels from baseline were significantly higher in daprodustat group than that in the placebo (mean difference (MD) = 1.73, [95% confidence interval (CI), 0.34 to 3.12], p = 0.01; MD = 1.88, [95% CI, 0.68 to 3.09], p = 0.002; respectively), and there was no significant difference between daprodustat and rhEPO group (MD = 0.05, [95% CI, −0.49 to 0.59], p = 0.86; MD = 0.12, [95% CI, −0.28 to 0.52], p = 0.55; respectively). The indexes of iron metabolism were improved significantly in the daprodustat group compared to placebo- or rhEPO-treated patients, while there was no similar change in terms of TSAT for DD patients. Furthermore, no trend of increasing plasma VEGF was observed in daprodustat-treated subjects. As for safety, there was no significant difference in the incidence of SAEs between daprodustat and placebo treatment, while the incidence of SAEs in the daprodustat group was significantly lower than that in the rhEPO group. Conclusion: Daprodustat was efficacious and well tolerated for anemia in both NDD and DD patients in the short term based on current RCTs. And daprodustat may become an effective alternative for treatment of anemia with CKD. Since the application of daprodustat is still under exploration, future researches should consider the limitations of our study to evaluate the value of daprodustat.
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Affiliation(s)
- Qiyan Zheng
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yahui Wang
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Huisheng Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Luying Sun
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xinwen Fu
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Ruojun Wei
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yu Ning Liu
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Wei Jing Liu
- Renal Research Institution of Beijing University of Chinese Medicine, Beijing, China.,Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China.,Institute of Nephrology, and Zhanjiang Key Laboratory of Prevention and Management of Chronic Kidney Disease, Guangdong Medical University, Zhanjiang, China
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64
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Long-Term Prognosis of Hyperferritinemia Induced by Intravenous Iron Therapy in Patients Undergoing Maintenance Hemodialysis: A 10-Year, Single-Center Study. Int J Nephrol 2021; 2020:8864400. [PMID: 33381315 PMCID: PMC7762662 DOI: 10.1155/2020/8864400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Optimal ferritin level in hemodialysis patients between Japan and other countries is controversial. Long-term side effects of iron supplementation in these patients remain unclear. We aimed to elucidate whether past hyperferritinemia in hemodialysis patients was associated with high risk of death and cerebrovascular and cardiovascular diseases (CCVDs). This small retrospective cohort study included approximately 44 patients unintentionally supplemented with excessive intravenous iron. A significantly higher risk of CCVDs was observed in patients with initial serum ferritin levels ≥1000 ng/mL than in the remaining patients. High ferritin levels slowly decreased to <300 ng/mL in a median of 24.2 (10.5–46.5) months without treatment. However, compared with the remaining patients, only patients whose ferritin levels did not decrease to <300 ng/mL steadily had a significantly higher risk of all-cause death (hazard ratio, 9.6). Long-term hyperferritinemia due to intravenous iron therapy is a risk factor for death in maintenance hemodialysis patients. For a prolonged better prognosis, intravenous iron should be carefully administered so as to avoid hyperferritinemia in patients with hemodialysis.
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65
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Stewart T, Lambourne J, Thorp-Jones D, Thomas DW. Implementation of early management of iron deficiency in pregnancy during the SARS-CoV-2 pandemic. Eur J Obstet Gynecol Reprod Biol 2020; 258:60-62. [PMID: 33418463 PMCID: PMC7774011 DOI: 10.1016/j.ejogrb.2020.12.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 12/05/2022]
Abstract
Iron deficiency is the commonest cause for anaemia worldwide making it a formidable issue particularly during pregnancy because of increased iron demands. This study looked at establishing a lower limit of normal for haemoglobin concentration (Hb) in our population and to proactively address potentially symptomatic iron deficiency during the current SARS-CoV-2 pandemic. The lower limit of normal for Hb in our 1715 first trimester pregnancy cohort was 116 g/L. This is in contrast with guidance suggesting Hb levels down to 110 g/L are normal. In addition there was evidence of limited testing performed to look for iron deficiency with only 18 % having a serum ferritin checked. Most anaemia was normocytic suggesting that microcytosis is only a late marker of iron deficiency lacking sensitivity. A strategy to avoid hospital contact during the COVID-19 pandemic is proposed.
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Affiliation(s)
- T Stewart
- University Hospitals Plymouth NHS Trust, Plymouth, Devon, PL6 8DH, United Kingdom
| | - J Lambourne
- East Kent Hospitals NHS Foundation Trust, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, TN24 0LZ, United Kingdom
| | - D Thorp-Jones
- University Hospitals Plymouth NHS Trust, Plymouth, Devon, PL6 8DH, United Kingdom
| | - D W Thomas
- University Hospitals Plymouth NHS Trust, Plymouth, Devon, PL6 8DH, United Kingdom.
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66
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Kalra PA, Bhandari S, Spyridon M, Davison R, Lawman S, Mikhail A, Reaich D, Pritchard N, McCafferty K, Moore J. NIMO-CKD-UK: a real-world, observational study of iron isomaltoside in patients with iron deficiency anaemia and chronic kidney disease. BMC Nephrol 2020; 21:539. [PMID: 33302891 PMCID: PMC7726614 DOI: 10.1186/s12882-020-02180-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/19/2020] [Indexed: 12/21/2022] Open
Abstract
Background Intravenous iron is often used to treat iron deficiency anaemia in non-dialysis chronic kidney disease (ND-CKD), but the optimal dosing regimen remains unclear. We evaluated the impact of high- versus low-dose intravenous iron isomaltoside on the probability of retreatment with intravenous iron in iron-deficient ND-CKD patients. Methods This real-world, prospective, observational study collected data from 256 ND-CKD patients treated for anaemia in the UK. Following an initial course of iron isomaltoside, patients were followed for ≥12 months. Iron dose and the need for retreatment were determined at the investigators’ discretion. The primary study outcome was the need for retreatment at 52 weeks compared between patients who received >1000 mg of iron during Course 1 and those who received ≤1000 mg. Safety was evaluated through adverse drug reactions. Results The probability of retreatment at Week 52 was significantly lower in the >1000 mg iron group (n = 58) versus the ≤1000 mg group (n = 198); hazard ratio (95% confidence interval [CI]): 0.46 (0.20, 0.91); p = 0.012. Mean (95% CI) haemoglobin increased by 6.58 (4.94, 8.21) g/L in the ≤1000 mg group and by 10.59 (7.52, 13.66) g/L in the >1000 mg group (p = 0.024). Changes in other blood and iron parameters were not significantly different between the two groups. Administering >1000 mg of iron isomaltoside saved 8.6 appointments per 100 patients compared to ≤1000 mg. No serious adverse drug reactions were reported. Of the patients who received ≤1000 mg of iron in this study, 82.3% were eligible for a dose >1000 mg. Conclusions The >1000 mg iron isomaltoside regimen reduced the probability of retreatment, achieved a greater haemoglobin response irrespective of erythropoiesis-stimulating agent treatment, and reduced the total number of appointments required, compared to the ≤1000 mg regimen. Many of the patients who received ≤1000 mg of iron were eligible for >1000 mg, indicating that there was considerable underdosing in this study. Trial registration ClinicalTrials.gov NCT02546154, 10 September 2015.
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Affiliation(s)
| | | | | | | | | | | | - David Reaich
- The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jason Moore
- Royal Devon and Exeter University Hospital, Exeter, UK
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67
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Iorember F, Aviles D, Bamgbola O. Impact of immediate post-transplant parenteral iron therapy on the prevalence of anemia and short-term allograft function in a cohort of pediatric and adolescent renal transplant recipients. Pediatr Transplant 2020; 24:e13787. [PMID: 32678506 DOI: 10.1111/petr.13787] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/14/2020] [Accepted: 06/16/2020] [Indexed: 12/29/2022]
Abstract
Anemia is common but under-diagnosed and often inadequately treated in KTX recipients. ID is the major cause of early-onset anemia. We introduced routine use of parenteral (IV) iron in patients (2-18 years) who had KTX between January 2011 and December 2015. We explored the clinical benefits of this practice by comparing the iron-treated subjects [TX] with historical controls who had KTX between 2005 and 2010. The prevalence of anemia at 6 months (early-onset) for the cohort (both the study group and controls) was 55% and for anemia at 12 months (late-onset) was 60%. Although cause-effect relationship may not be proven in a retrospective study design, there was a significant greater frequency of ID and anemia at 3 (P < .02) and 6 months (P < .04), and a reduced allograft function (eGFR < 60 mL/min/1.73 m2 ) at 12 (P = .03) and 24 months (P = .04) of KTX in the control arm. Furthermore, a greater proportion of the control arm required either ESA (P = .03) or blood transfusion (P = .04) as a rescue treatment for moderate-to-severe anemia. In conclusion, routine parenteral iron treatment was associated with a lower prevalence of early- and late-onset anemia, and a lower requirement for either ESA rescue or blood transfusion.
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Affiliation(s)
- Franca Iorember
- Division of Pediatric Nephrology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Diego Aviles
- Division of Pediatric Nephrology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Oluwatoyin Bamgbola
- Division of Pediatric Nephrology, SUNY Downstate Medical Center, Brooklyn, New York, USA
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68
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Richards T, Baikady RR, Clevenger B, Butcher A, Abeysiri S, Chau M, Macdougall IC, Murphy G, Swinson R, Collier T, Van Dyck L, Browne J, Bradbury A, Dodd M, Evans R, Brealey D, Anker SD, Klein A. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. Lancet 2020; 396:1353-1361. [PMID: 32896294 PMCID: PMC7581899 DOI: 10.1016/s0140-6736(20)31539-7] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Preoperative anaemia affects a high proportion of patients undergoing major elective surgery and is associated with poor outcomes. We aimed to test the hypothesis that intravenous iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusions, and improve patient outcomes. METHODS In a double-blind, parallel-group randomised trial, we recruited adult participants identified with anaemia at preoperative hospital visits before elective major open abdominal surgery at 46 UK tertiary care centres. Anaemia was defined as haemoglobin less than 130 g/L for men and 120 g/L for women. We randomly allocated participants (1:1) via a secure web-based service to receive intravenous iron or placebo 10-42 days before surgery. Intravenous iron was administered as a single 1000 mg dose of ferric carboxymaltose in 100 mL normal saline, and placebo was 100 mL normal saline, both given as an infusion over 15 min. Unblinded study personnel prepared and administered the study drug; participants and other clinical and research staff were blinded to treatment allocation. Coprimary endpoints were risk of the composite outcome of blood transfusion or death, and number of blood transfusions from randomisation to 30 days postoperatively. The primary analysis included all randomly assigned patients with data available for the primary endpoints; safety analysis included all randomly assigned patients according to the treatment received. This study is registered, ISRCTN67322816, and is closed to new participants. FINDINGS Of 487 participants randomly assigned to placebo (n=243) or intravenous iron (n=244) between Jan 6, 2014, and Sept 28, 2018, complete data for the primary endpoints were available for 474 (97%) individuals. Death or blood transfusion occurred in 67 (28%) of the 237 patients in the placebo group and 69 (29%) of the 237 patients in the intravenous iron group (risk ratio 1·03, 95% CI 0·78-1·37; p=0·84). There were 111 blood transfusions in the placebo group and 105 in the intravenous iron group (rate ratio 0·98, 95% CI 0·68-1·43; p=0·93). There were no significant differences between the two groups for any of the prespecified safety endpoints. INTERPRETATION Preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10-42 days before elective major abdominal surgery. FUNDING UK National Institute of Health Research Health Technology Assessment Program.
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Affiliation(s)
- Toby Richards
- Division of Surgery, University of Western Australia, Fiona Stanley Hospital, Perth, WA, Australia; Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK.
| | | | - Ben Clevenger
- Department of Anaesthesia, Royal National Orthopaedic Hospital, London, UK
| | - Anna Butcher
- Division of Surgery, University College London, London, UK
| | - Sandy Abeysiri
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | - Marisa Chau
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | | | - Gavin Murphy
- NIHR Leicester Biomedical Research Centre, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rebecca Swinson
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim Collier
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Van Dyck
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | - Andrew Bradbury
- University Department of Vascular Surgery, Birmingham University, Solihull Hospital, Solihull, UK
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - David Brealey
- Institute of Clinical Trials and Methodology, University College London, London, UK; Division of Surgery, University College London, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies, and German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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69
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Vinke JSJ, Francke MI, Eisenga MF, Hesselink DA, de Borst MH. Iron deficiency after kidney transplantation. Nephrol Dial Transplant 2020; 36:1976-1985. [PMID: 32910168 PMCID: PMC8577626 DOI: 10.1093/ndt/gfaa123] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Indexed: 12/30/2022] Open
Abstract
Iron deficiency (ID) is highly prevalent in kidney transplant recipients (KTRs) and has been independently associated with an excess mortality risk in this population. Several causes lead to ID in KTRs, including inflammation, medication and an increased iron need after transplantation. Although many studies in other populations indicate a pivotal role for iron as a regulator of the immune system, little is known about the impact of ID on the immune system in KTRs. Moreover, clinical trials in patients with chronic kidney disease or heart failure have shown that correction of ID, with or without anaemia, improves exercise capacity and quality of life, and may improve survival. ID could therefore be a modifiable risk factor to improve graft and patient outcomes in KTRs; prospective studies are warranted to substantiate this hypothesis.
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Affiliation(s)
- Joanna Sophia J Vinke
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marith I Francke
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michele F Eisenga
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Martin H de Borst
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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70
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Zhang J, Hu S, Jiang Y, Zhou Y. Efficacy and safety of iron therapy in patients with chronic heart failure and iron deficiency: a systematic review and meta-analysis based on 15 randomised controlled trials. Postgrad Med J 2020; 96:766-776. [PMID: 32843482 DOI: 10.1136/postgradmedj-2019-137342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 11/04/2022]
Abstract
Trials studying iron administration in patients with chronic heart failure (CHF) and iron deficiency (ID) have sprung up these years but the results remain inconsistent. The aim of this meta-analysis was to comprehensively evaluate the efficacy and safety of iron therapy in patients with CHF and ID. A literature search was conducted across PubMed, Embase, Cochrane Library, OVID and Web of Science up to 31 July 2019 to search for randomised controlled trials (RCT) comparing iron therapy with placebo in CHF with ID, regardless of presence of anaemia. Published studies reporting data of any of the following outcomes were included: all-cause death, cardiovascular hospitalisation, adverse events, New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF), N-terminal pro b-type natriuretic peptide, peak oxygen consumption, 6 min walking test (6MWT) distance and quality of life (QoL) parameters. 15 RCTs with a total of 1627 patients (911 in iron therapy and 716 in control) were included. Iron therapy was demonstrated to reduce the risk of cardiovascular hospitalisation (OR 0.35, 95% CI 0.12 to 0.99, p=0.049), but was ineffective in reducing all-cause death (OR 0.59, 95% CI 0.33 to 1.06, p=0.078) or cardiovascular death (OR 0.80, 95% CI 0.39 to 1.63, p=0.540). Iron therapy resulted in a reduction in NYHA class (mean difference (MD) -0.73, 95% CI -0.99 to -0.47, p<0.001), an increase in LVEF (MD +4.35, 95% CI 0.69 to 8.00, p=0.020), 6MWT distance (MD +35.44, 95% CI 11.55 to 59.33, p=0.004) and an improvement in QoL: EQ-5D score (MD +4.07, 95% CI 0.84 to 7.31, p=0.014); Minnesota Living With Heart Failure Questionnaire score (MD -19.47, 95% CI -23.36 to -15.59, p<0.001) and Patients Global Assessment (PGA) scale (MD 0.71, 95% CI 0.32 to 1.10, p<0.001). There was no significant difference in adverse events or serious adverse events between iron treatment group and control group. Iron therapy reduces cardiovascular hospitalisation in patients with CHF with ID, and additionally improves cardiac function, exercise capacity and QoL in patients with CHF with ID and anaemia, without an increase of adverse events.
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Affiliation(s)
- Junyi Zhang
- Department of Cardiology, The First Affilisted Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shengda Hu
- Department of Cardiology, The First Affilisted Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yufeng Jiang
- Department of Cardiology, The First Affilisted Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yafeng Zhou
- Department of Cardiology, The First Affilisted Hospital of Soochow University, Suzhou, Jiangsu, China
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71
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Vaught K, Kerber S. Evolution of Treatment for Anemia in Chronic Kidney Disease. J Ren Nutr 2020; 30:e67-e70. [PMID: 32703669 DOI: 10.1053/j.jrn.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/26/2020] [Indexed: 11/11/2022] Open
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72
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Susantitaphong P, Siribumrungwong M, Takkavatakarn K, Chongthanakorn K, Lieusuwan S, Katavetin P, Tiranathanagul K, Lekhyananda S, Tungsanga K, Vanichakarn S, Eiam-Ong S, Praditpornsilpa K. Effect of Maintenance Intravenous Iron Treatment on Erythropoietin Dose in Chronic Hemodialysis Patients: A Multicenter Randomized Controlled Trial. Can J Kidney Health Dis 2020; 7:2054358120933397. [PMID: 32612843 PMCID: PMC7307402 DOI: 10.1177/2054358120933397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background: There is no consensus on intravenous (IV) iron supplement dose, schedule, and
serum ferritin target in functional iron deficiency anemia to maintain
optimum target levels of iron stores by several guidelines. Objective: To examine the effect of IV iron supplementation to different targets of
serum ferritin on erythropoietin dose and inflammatory markers in chronic
hemodialysis (HD) patients with functional iron deficiency anemia. Design: A multicenter, randomized, open-label study. Setting: In a developing country, Thailand. Patients: Chronic HD patients with functional iron deficiency anemia. Measurements: Erythropoietin resistance index, high-sensitivity C-reactive protein, and
fibroblast growth factor 23. Methods: Two hundred adult chronic HD patients with transferrin saturation less than
30% and serum ferritin of 200 to 400 ng/mL were randomized 1:1 to maintain
serum ferritin 200 to 400 ng/mL (low-serum ferritin group, N = 100) or 600
to 700 ng/mL (high-serum ferritin group, N = 100). During a 6-week titration
period, participants randomized to the high-serum ferritin group initially
received 600 mg IV iron (100 mg every week), while the participants in the
low-serum ferritin group did not receive IV iron. During the 6-month
follow-up period, the dose of IV iron was adjusted by protocol. Results: The mean dose of IV iron was 108.3 ± 28.2 mg/month in the low-serum ferritin
group and 192.3 ± 36.2 mg/month in the high-serum ferritin group. The mean
serum ferritin was 367.0 ± 224.9 ng/mL in the low ferritin group and 619.6 ±
265.2 ng/mL in the high ferritin group. The erythropoietin resistance index
was significantly decreased in the high-serum ferritin group compared to the
low-serum ferritin group after receiving IV iron in the 6-week titration
period (mean difference: −113.43 ± 189.14 vs 41.08 ± 207.38 unit/week/g/dL;
P < .001) and 3-month follow-up period (mean
differences: −88.88 ± 234.43 vs −10.48 ± 217.75 unit/week/g/dL;
P = .02). Limitations: Short follow-up period. Conclusion: Maintaining a serum ferritin level of 600 to 700 ng/mL by IV iron
administration of approximately 200 mg per month as a maintenance protocol
can decrease erythropoietin dose requirements in chronic HD patients with
functional iron deficiency anemia. Trials registration: The study was registered with the Thai Clinical Trials Registry
TCTR20180903003.
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Affiliation(s)
- Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Thailand
| | - Monchai Siribumrungwong
- Nephrology Unit, Department of Medicine, Lerdsin Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | | | - Pisut Katavetin
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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73
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Macdougall IC, Comin-Colet J, Breymann C, Spahn DR, Koutroubakis IE. Iron Sucrose: A Wealth of Experience in Treating Iron Deficiency. Adv Ther 2020; 37:1960-2002. [PMID: 32297281 PMCID: PMC7467495 DOI: 10.1007/s12325-020-01323-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/19/2022]
Abstract
Iron deficiency and iron-deficiency anemia are associated with increased morbidity and mortality in a wide range of conditions. In many patient populations, this can be treated effectively with oral iron supplementation; but in patients who are unable to take or who do not respond to oral iron therapy, intravenous iron administration is recommended. Furthermore, in certain conditions, such as end-stage kidney disease, chronic heart failure, and inflammatory bowel disease, intravenous iron administration has become first-line treatment. One of the first available intravenous iron preparations is iron sucrose (Venofer®), a nanomedicine that has been used clinically since 1949. Treatment with iron sucrose is particularly beneficial owing to its ability to rapidly increase hemoglobin, ferritin, and transferrin saturation levels, with an acceptable safety profile. Recently, important new data relating to the use of iron sucrose, including the findings from the landmark PIVOTAL trial in patients with end-stage kidney disease, have been reported. Several years ago, a number of iron sucrose similars became available, although there have been concerns about the clinical appropriateness of substituting the original iron sucrose with an iron sucrose similar because of differences in efficacy and safety. This is a result of the complex and unique physicochemical properties of nanomedicines such as iron sucrose, which make copying the molecule difficult and problematic. In this review, we summarize the evidence accumulated during 70 years of clinical experience with iron sucrose in terms of efficacy, safety, and cost-effectiveness.
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Affiliation(s)
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zürich, Zurich, Switzerland
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74
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The Impact of Iron Supplementation for Treating Anemia in Patients with Chronic Kidney Disease: Results from Pairwise and Network Meta-Analyses of Randomized Controlled Trials. Pharmaceuticals (Basel) 2020; 13:ph13050085. [PMID: 32365757 PMCID: PMC7281268 DOI: 10.3390/ph13050085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022] Open
Abstract
After relative erythropoietin deficiency, iron deficiency is the second most important contributing factor for anemia in chronic kidney disease (CKD) patients. Iron supplementation is a crucial part of the treatment of anemia in CKD patients, and intravenous (IV) iron supplementation is considered to be superior to per os (PO) iron supplementation. The differences between the available formulations are poorly characterized. This report presents results from pairwise and network meta-analyses carried out after a comprehensive search in sources of published and unpublished studies, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations (International prospective register of systematic reviews PROSPERO reference ID: CRD42020148155). Meta-analytic calculations were performed for the outcome of non-response to iron supplementation (i.e., hemoglobin (Hgb) increase of <0.5–1.0 g/dL, or initiation/intensification of erythropoiesis-stimulating agent (ESA) therapy, or increase/change of iron supplement, or requirements of blood transfusion). A total of 34 randomized controlled trials (RCT) were identified, providing numerical data for analyses covering 93.7% (n = 10.097) of the total study population. At the network level, iron supplementation seems to have a more protective effect against the outcome of non-response before the start of dialysis than once dialysis is initiated, and some preparations seem to be more potent (e.g., ferumoxytol, ferric carboxymaltose), compared to the rest of iron supplements assessed (surface under the cumulative ranking area (SUCRA) > 0.8). This study provides parameters for adequately following-up patients requiring iron supplementation, by presenting the most performing preparations, and, indirectly, by making it possible to identify good responders among all patients treated with these medicines.
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75
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Staibano P, Perelman I, Lombardi J, Davis A, Tinmouth A, Carrier M, Stevenson C, Saidenberg E. Patient-Centred Outcomes in Anaemia and Renal Disease: A Systematic Review. KIDNEY DISEASES 2020; 6:74-84. [PMID: 32309289 DOI: 10.1159/000502208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022]
Abstract
Background Anaemia is a nearly universal complication of chronic kidney disease (CKD). Erythropoiesis-stimulating agents (ESAs) have been demonstrated to improve clinical outcomes and quality of life (QOL) in renal patients with anaemia. Patient-reported outcome measures (PROMs) are increasingly being used to evaluate the patient-centred impact of medical therapy. Here, we describe a systematic review of studies that evaluated patient-centred outcomes (PCOs) in renal patients undergoing anaemia treatment. Methods We conducted a search of Medline (Ovid), EMBASE (Ovid), PsychINFO, and CINAHL databases for studies published until March 2018 that investigated an intervention to treat anaemia in renal patients and used at least one PROM. We also performed a quality assessment for all included studies. Statistical analyses characterized each study, PROMs used, the quality of PCO reporting, and the association between haematological outcomes and PCOs. Results Of the 3,533 studies identified in the database search, 21 met all eligibility criteria. Fourteen (67%) of the studies were randomized-controlled trials. Most studies (81%) investigated CKD patients, 14% investigated post-renal transplant patients and 5% assessed patients with heart disease on haemodialysis. The most common anaemia intervention, used in 95% of studies, was ESAs. Forty-three percent of studies utilized one PROM, most commonly the SF-36, a measure of QOL not specifically created for use in nephrology patients. About a third of studies selectively reported PROM subscales, rather than reporting all subscales. Notable biases among included studies included lack of blinding, selective outcome reporting, and lack of power estimates for PCOs. We did not find a statistically significant association between improvements in haemoglobin and QOL. Conclusions Future studies employing anaemia and nephrology-specific PROMs and conducted with greater rigour, standardization in the research methods, and reporting of PCOs in renal populations will improve understanding of PCOs in this patient group and hopefully improve patient outcomes and experiences.
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Affiliation(s)
- Phillip Staibano
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia Lombardi
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Alan Tinmouth
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marc Carrier
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Elianna Saidenberg
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
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76
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Auerbach M, Gafter-Gvili A, Macdougall IC. Intravenous iron: a framework for changing the management of iron deficiency. LANCET HAEMATOLOGY 2020; 7:e342-e350. [PMID: 32220343 DOI: 10.1016/s2352-3026(19)30264-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
For decades intravenous iron was considered dangerous. Newer formulations with carbohydrate cores binding elemental iron more tightly allow complete iron replacement within 15-60 min in one visit. Meta-analyses and prospective comparisons of different formulations support equivalent safety to placebo with less toxicity than oral iron. Of the available formulations, the preponderance of published evidence supports equal safety and efficacy. In this Viewpoint, we report evidence supporting repositioning of intravenous iron to the frontline in multiple disorders with iron deficiency, which include heart failure, chronic kidney disease, inflammatory bowel disease, patient blood management in the perioperative period, and obstetrics and gynaecology. We have also highlighted neonatal evidence supporting the inadequacy of oral iron in late pregnancy, a critical period of iron need for normal foetal brain development. Physicians should consider prioritising the use of intravenous iron rather than oral iron as a treatment for iron deficiency in some of these clinical scenarios.
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77
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Ganz T, Aronoff GR, Gaillard CAJM, Goodnough LT, Macdougall IC, Mayer G, Porto G, Winkelmayer WC, Wish JB. Iron Administration, Infection, and Anemia Management in CKD: Untangling the Effects of Intravenous Iron Therapy on Immunity and Infection Risk. Kidney Med 2020; 2:341-353. [PMID: 32734254 PMCID: PMC7380433 DOI: 10.1016/j.xkme.2020.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Patients with chronic kidney disease (CKD) are at increased risk for infection, attributable to immune dysfunction, increased exposure to infectious agents, loss of cutaneous barriers, comorbid conditions, and treatment-related factors (eg, hemodialysis and immunosuppressant therapy). Because iron plays a vital role in pathogen reproduction and host immunity, it is biologically plausible that intravenous iron therapy and/or iron deficiency influence infection risk in CKD. Available data from preclinical experiments, observational studies, and randomized controlled trials are summarized to explore the interplay between intravenous iron and infection risk among patients with CKD, particularly those receiving maintenance hemodialysis. The current evidence base, including data from a recent randomized controlled trial, suggests that proactive judicious use of intravenous iron (in a manner that minimizes the accumulation of non-transferrin-bound iron) beneficially replaces iron stores while avoiding a clinically relevant effect on infection risk. In the absence of an urgent clinical need, intravenous iron therapy should be avoided in patients with active infection. Although serum ferritin concentration and transferrin saturation can help guide clinical decision making about intravenous iron therapy, definition of an optimal iron status and its precise determination in individual patients remain clinically challenging in CKD and warrant additional study.
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Affiliation(s)
- Tomas Ganz
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | | | | | - Lawrence T Goodnough
- Department of Pathology, Stanford University, Stanford, CA.,Department of Medicine (Hematology), Stanford University, Stanford, CA
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Graça Porto
- Pathology and Molecular Immunology Department, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,i3S, Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay B Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN
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78
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Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron Deficiency in Chronic Kidney Disease: Updates on Pathophysiology, Diagnosis, and Treatment. J Am Soc Nephrol 2020; 31:456-468. [PMID: 32041774 PMCID: PMC7062209 DOI: 10.1681/asn.2019020213] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Anemia is a complication that affects a majority of individuals with advanced CKD. Although relative deficiency of erythropoietin production is the major driver of anemia in CKD, iron deficiency stands out among the mechanisms contributing to the impaired erythropoiesis in the setting of reduced kidney function. Iron deficiency plays a significant role in anemia in CKD. This may be due to a true paucity of iron stores (absolute iron deficiency) or a relative (functional) deficiency which prevents the use of available iron stores. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood losses, impaired iron absorption, and chronic inflammation. The traditional biomarkers used for the diagnosis of iron-deficiency anemia (IDA) in patients with CKD have limitations, leading to persistent challenges in the detection and monitoring of IDA in these patients. Here, we review the pathophysiology and available diagnostic tests for IDA in CKD, we discuss the literature that has informed the current practice guidelines for the treatment of IDA in CKD, and we summarize the available oral and intravenous (IV) iron formulations for the treatment of IDA in CKD. Two important issues are addressed, including the potential risks of a more liberal approach to iron supplementation as well as the potential risks and benefits of IV versus oral iron supplementation in patients with CKD.
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Affiliation(s)
| | - Pinelopi Kapitsinou
- Feinberg Cardiovascular and Renal Research Institute and
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pablo E Pergola
- Renal Associates PA, Division of Nephrology, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Diana I Jalal
- Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
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79
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Touzot M, Lefebvre T, Maheas C, Ridel C, Puy H, Karim Z. A hepcidin-based approach for iron therapy in hemodialysis patients: A pilot study. Hemodial Int 2020; 24:188-194. [PMID: 32048444 DOI: 10.1111/hdi.12823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/20/2020] [Accepted: 01/26/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Hepcidin is a key factor that regulates iron homeostasis. In hemodialysis patients (HD), a high hepcidin level may decrease intestinal iron absorption and reduce the efficacy of Oral iron vs Intravenous iron therapy. Whether the hepcidin level in HD could guide oral iron therapy is unclear. METHODS We report a monocentric study on nine "erythropoietin (EPO)-free" patients (without recombinant human EPO [rHU-EPO] for at least 6 months) and normal hepcidin level (<20 ng mL) during the study. After 15 days of washout, oral iron (ferrous sulfate 80 mg/day) was introduced. The primary end point was the hemoglobin response and iron store at 3 months. FINDINGS Nine patients (8 men, 1 woman) with a median age of 62 years (range 42-79) were included. After 1 week of treatment, the median transferrin saturation index increased from 15% (range 6-61) to 34% (range 13-42), P = 0.62, reflecting intestinal absorption. The median ferritin level remained stable 80 μg/L (35-293) vs 82 μg/L (range 37-496) between M0 and M3, P = 0.43. During the 3-month study, median hemoglobin level increased from 11.5 d/dL (range10.4-13.7) to 12.8 g/dL (range 11.1-15.2), P = 0.01. No major side effects were observed. Quality of life assessed by the SF-36 criteria was similar during the 3-month study. DISCUSSION Oral iron therapy is effective and safe in EPO-free patients with normal hepcidin levels. These findings suggest that serum hepcidin may be a marker for defining iron therapy strategies in HD patients. HD patients treated with rHU-EPO and with normal hepcidin levels could benefit from oral iron treatment.
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Affiliation(s)
| | - Thibaud Lefebvre
- Institut National de Santé en Recherche Médicale (INSERM) U1149, Centre de recherche sur l'inflammation, Paris, France.,Centre Français des Porphyries, Hopîtal Louis Mourier, Colombes, France
| | | | | | - Hervé Puy
- Institut National de Santé en Recherche Médicale (INSERM) U1149, Centre de recherche sur l'inflammation, Paris, France.,Centre Français des Porphyries, Hopîtal Louis Mourier, Colombes, France
| | - Zoubida Karim
- Institut National de Santé en Recherche Médicale (INSERM) U1149, Centre de recherche sur l'inflammation, Paris, France.,Centre Français des Porphyries, Hopîtal Louis Mourier, Colombes, France
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80
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Koo CH, Shin HJ, Cho H, Ryu JH. The Effect of Perioperative Intravenous Iron on Hemoglobin in Surgical Patients: A Meta-Analysis. J Surg Res 2020; 246:42-51. [DOI: 10.1016/j.jss.2019.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/26/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022]
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81
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Portolés-Pérez J, Durá-Gúrpide B, Merino-Rivas JL, Martín-Rodriguez L, Hevia-Ojanguren C, Burguera-Vion V, Yuste-Lozano C, Sánchez-García L, Rodriguez-Palomares JR, Paraiso V. Effectiveness and safety of ferric carboxymaltose therapy in peritoneal dialysis patients: an observational study. Clin Kidney J 2019; 14:174-180. [PMID: 33564416 PMCID: PMC7857829 DOI: 10.1093/ckj/sfz153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Background The efficacy of intravenous (IV) ferric carboxymaltose (FCM) has been demonstrated in haemodialysis and non-dialysis studies, but evidence is lacking in patients undergoing peritoneal dialysis (PD). Methods This multicentre, retrospective study evaluated the effectiveness and safety of FCM in patients on PD over 12 months. We retrospectively reviewed the electronic medical records of PD patients who initiated FCM treatment between 2014 and 2017 across seven Spanish centres. Results Ninety-one patients were included in the safety population (mean ± SD age 57.7 ± 15.0 years) and 70 in the efficacy population (mean age 50.9 ± 14.5 years). No hypersensitivity reaction, FCM discontinuation or dose adjustment due to a serious adverse event (SAE) was registered in the safety population. The most common non-SAEs reported were headache (four events), mild hypotension (three events) and hypertension (two events), among others. In the efficacy population (n = 70), 68.6% of patients achieved ferritin levels of 200–800 ng/mL, 78.4% achieved transferrin saturation (TSAT) >20%, and 62.8% achieved TSAT >20% and ferritin >200 ng/mL after 12 months of FCM initiation (P < 0.01). Haemoglobin (Hb) levels were maintained at >11 g/dL with a lower dose of darbepoetin throughout the follow-up. The sub-analysis of patients naïve to IV iron and with absolute or relative iron deficiency (n = 51) showed that 76.5% reached ferritin >200 ng/mL, 80.4% TSAT >20% and Hb increased (1.2 g/dL) after 4 months of FCM treatment (P < 0.01). Conclusion In this multicentre, retrospective, real-world study conducted in the PD population, FCM was effective, safe and easy to administer during routine clinical visits.
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Affiliation(s)
- Jose Portolés-Pérez
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | - Beatriz Durá-Gúrpide
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | | | - Leyre Martín-Rodriguez
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | | | - Victor Burguera-Vion
- RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain.,Nephrology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Claudia Yuste-Lozano
- RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain.,Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | | | | | - Vicente Paraiso
- Nephrology Department, University Hospital del Henares, Coslada, Madrid, Spain
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82
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Macdougall IC. Intravenous Iron Use in the Care of Patients with Kidney Disease. Clin J Am Soc Nephrol 2019; 14:1528-1530. [PMID: 31175103 PMCID: PMC6777593 DOI: 10.2215/cjn.00510119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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83
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Daimon S. Efficacy for Anemia and Changes in Serum Ferritin Levels by Long‐Term Oral Iron Administration in Hemodialysis Patients. Ther Apher Dial 2019; 23:444-450. [DOI: 10.1111/1744-9987.12795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Shoichiro Daimon
- Department of Nephrology, Daimon Clinic for Internal MedicineNephrology and Dialysis Nonoichi Japan
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84
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Wang F, Lv H, Zhao B, Zhou L, Wang S, Luo J, Liu J, Shang P. Iron and leukemia: new insights for future treatments. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2019; 38:406. [PMID: 31519186 PMCID: PMC6743129 DOI: 10.1186/s13046-019-1397-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/27/2019] [Indexed: 01/19/2023]
Abstract
Iron, an indispensable element for life, is involved in all kinds of important physiological activities. Iron promotes cell growth and proliferation, but it also causes oxidative stress damage. The body has a strict regulation mechanism of iron metabolism due to its potential toxicity. As a cancer of the bone marrow and blood cells, leukemia threatens human health seriously. Current studies suggest that dysregulation of iron metabolism and subsequent accumulation of excess iron are closely associated with the occurrence and progress of leukemia. Specifically, excess iron promotes the development of leukemia due to the pro-oxidative nature of iron and its damaging effects on DNA. On the other hand, leukemia cells acquire large amounts of iron to maintain rapid growth and proliferation. Therefore, targeting iron metabolism may provide new insights for approaches to the treatment of leukemia. This review summarizes physiologic iron metabolism, alternations of iron metabolism in leukemia and therapeutic opportunities of targeting the altered iron metabolism in leukemia, with a focus on acute leukemia.
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Affiliation(s)
- Fang Wang
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Huanhuan Lv
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China.,Research & Development Institute of Northwestern Polytechnical University in Shenzhen, Shenzhen, 518057, China.,Key Laboratory for Space Bioscience and Biotechnology, Institute of Special Environment Biophysics, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Bin Zhao
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Liangfu Zhou
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Shenghang Wang
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Jie Luo
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Junyu Liu
- School of Life Science, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Peng Shang
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, Shenzhen, 518057, China. .,Key Laboratory for Space Bioscience and Biotechnology, Institute of Special Environment Biophysics, Northwestern Polytechnical University, Xi'an, 710072, China.
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85
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Salim SA, Cheungpasitporn W, Elmaraezy A, Jawafi O, Rahman M, Aeddula NR, Tirupathi R, Fülöp T. Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis. Int Urol Nephrol 2019; 51:1855-1865. [PMID: 31485910 DOI: 10.1007/s11255-019-02273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. METHODS Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. RESULTS All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). CONCLUSION High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.
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Affiliation(s)
- Sohail Abdul Salim
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA.
| | - Wisit Cheungpasitporn
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA
| | | | - Omar Jawafi
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | - Md Rahman
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | | | | | - Tibor Fülöp
- Division of Nephrology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.,Raph H. Johnson VA Medical Center, Charleston, SC, USA
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86
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Akizawa T, Macdougall IC, Berns JS, Yamamoto H, Taguchi M, Iekushi K, Bernhardt T. Iron Regulation by Molidustat, a Daily Oral Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor, in Patients with Chronic Kidney Disease. Nephron Clin Pract 2019; 143:243-254. [PMID: 31387097 PMCID: PMC6979436 DOI: 10.1159/000502012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND/AIMS The current treatment for anemia associated with chronic kidney disease (CKD) includes the administration of erythropoiesis stimulating agents (ESAs) combined with iron supplementation. Molidustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor, has potential to treat anemia associated with CKD through increased erythropoietin production and improved iron availability. Here, we report the effect of molidustat on iron metabolism. METHOD Parameters of iron metabolism were monitored in three 16-week, randomized, controlled, phase 2 studies assessing the safety and efficacy of molidustat in the treatment of anemia associated with CKD in different populations: treatment-naïve and previously ESA-treated patients not on dialysis, and previously ESA-treated patients on hemodialysis. Iron supplementation was left at the discretion of the investigator. RESULTS In treatment-naïve patients not on dialysis, transferrin saturation (TSAT), hepcidin, ferritin, and iron concentrations decreased with molidustat, whereas total iron binding capacity (TIBC) increased. Similar results were observed in previously ESA-treated patients not on dialysis, although changes in those parameters were larger in treatment-naïve than in previously ESA-treated patients. In previously ESA-treated patients receiving hemodialysis, hepcidin concentration and TIBC remained stable with molidustat, whereas TSAT and ferritin and iron concentrations increased. Generally, similar trends were observed in secondary analyses of subgroups of patients not receiving iron supplementation. CONCLUSIONS Molidustat is a potential alternative to standard treatment of anemia associated with CKD, with a different mechanism of action. In patients not receiving dialysis, molidustat increases iron availability. In patients receiving hemodialysis, further investigation is required to understand fully the mechanisms underlying iron mobilization associated with molidustat.
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Affiliation(s)
- Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan,
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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87
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Karaboyas A, Morgenstern H, Waechter S, Fleischer NL, Vanholder R, Jacobson SH, Sood MM, Schaubel DE, Inaba M, Pisoni RL, Robinson BM. Low hemoglobin at hemodialysis initiation: an international study of anemia management and mortality in the early dialysis period. Clin Kidney J 2019; 13:425-433. [PMID: 32699623 PMCID: PMC7367115 DOI: 10.1093/ckj/sfz065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 04/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background Anemia at hemodialysis (HD) initiation is common. Correcting low hemoglobin (Hgb) before HD initiation may improve survival by avoiding potential harms of chronic anemia, high doses of erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron in the early HD period, and/or rapid Hgb rise. Methods We included 4604 incident HD patients from 21 countries in the Dialysis Outcomes and Practice Patterns Study Phases 4–5 (2009–15). Because low Hgb at HD start may reflect comorbidity or ESA hyporesponse, we restricted our analysis to the 80% of patients who achieved Hgb ≥10 g/dL 91–120 days after HD start (Month 4). Results About 53% of these patients had Hgb <10 g/dL in Month 1 (<30 days after HD start); they were younger with a similar comorbidity profile (versus Hgb ≥10 g/dL). Month 1 Hgb was associated with first-year HD mortality (adjusted hazard ratio for 1 g/dL higher Hgb was 0.89; 95% confidence interval: 0.81–0.97), despite minimal differences in Month 4 Hgb. Patients with lower Hgb in Month 1 received higher doses of ESA, but not IV iron, over the first 3 months of HD. Results were consistent when excluding catheter users or adjusting for IV iron and ESA dose over the first 3 months. Conclusions Even among patients with Hgb ≥10 g/dL 3 months later, anemia at HD initiation was common and associated with elevated mortality. A more proactive approach to anemia management in advanced chronic kidney disease (CKD) may thus improve survival on HD, though long-term prospective studies of non-dialysis CKD patients are needed.
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Affiliation(s)
- Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Hal Morgenstern
- Department of Epidemiology and Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, Medical School, University of Michigan, Ann Arbor, MI, USA
| | | | - Nancy L Fleischer
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Stefan H Jacobson
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Manish M Sood
- Department of Medicine, School of Epidemiology and Public Health, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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88
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Pagès A, Porteils C, Labadens I, Parmier M, Oses S, Semely D, Bourdoncle M, Seigneuric B, Del Bello A, Juillard-Condat B. Cost-minimization analysis between intravenous iron sucrose and iron sucrose similar in hemodialysis patients. Expert Rev Pharmacoecon Outcomes Res 2019; 20:281-287. [PMID: 31257944 DOI: 10.1080/14737167.2019.1632193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Intravenous iron and erythropoiesis-stimulating agents are used to manage anemia in chronic hemodialysis patients. The interchangeability between intravenous iron sucrose preparations is still debated. We evaluated how cost and effectiveness were impacted when chronic hemodialysis patients were switched from an original iron sucrose product to an iron sucrose similar preparation. METHODS A single center sequential observational retrospective study was conducted at a French hospital. The same patients were followed during two 24-week periods (iron sucrose in period P1; and iron sucrose similar in period P2). Anemia-related treatment costs were assessed in P1 and P2 from a hospital perspective. Sensitivity analyses were performed to assess the robustness of the results. RESULTS Our study included 109 patients (105 analyzed patients and 4 patients with missing data). The mean hemoglobin level was not different between P1 and P2 (p = 0.92). The mean differential cost per patient was + €13.90 (P2 - P1). The factors with the biggest impact on this result were the prices of epoetin alfa and iron sucrose. CONCLUSION This cost minimization analysis suggests that for chronic hemodialysis patients, iron sucrose and iron sucrose similar have the same efficacy and that using iron sucrose similar was more expensive in 66.7% of iterations.
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Affiliation(s)
- Arnaud Pagès
- Department of Pharmacy, CHU de Toulouse , Toulouse, France.,UMR 1027, Inserm UPS Université de Toulouse III , Toulouse, France
| | | | | | | | - Samantha Oses
- Department of Pharmacy, CHU de Toulouse , Toulouse, France
| | - Damien Semely
- Department of Pharmacy, CHU de Toulouse , Toulouse, France
| | | | - Bruno Seigneuric
- Department of Nephrology, Dialysis and Organ Transplantation, CHU de Toulouse , Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology, Dialysis and Organ Transplantation, CHU de Toulouse , Toulouse, France
| | - Blandine Juillard-Condat
- Department of Pharmacy, CHU de Toulouse , Toulouse, France.,UMR 1027, Inserm UPS Université de Toulouse III , Toulouse, France
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89
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Pergola PE, Fishbane S, Ganz T. Novel Oral Iron Therapies for Iron Deficiency Anemia in Chronic Kidney Disease. Adv Chronic Kidney Dis 2019; 26:272-291. [PMID: 31477258 DOI: 10.1053/j.ackd.2019.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 12/26/2022]
Abstract
Iron deficiency anemia (IDA) is a frequent complication of chronic kidney disease (CKD) and is associated with adverse outcomes in these patients. Patients with CKD and IDA remain largely undertreated. Conventional oral iron agents are insufficiently effective due to poor absorption and cause gastrointestinal side effects; thus, novel oral iron preparations are needed. This article covers current treatment guidelines for patients with anemia and CKD and clinical trial data for iron-repletion agents currently in use, as well as for novel oral iron therapies in development. Ferric citrate, a novel oral iron-repletion agent approved for patients with non-dialysis-dependent CKD and IDA, demonstrated improvements in hemoglobin levels and iron parameters, with good tolerability in patients with non-dialysis-dependent CKD. When used as a phosphate binder, ferric citrate also improves hemoglobin and iron parameters in dialysis-dependent CKD, but additional trials are needed to evaluate its efficacy as an iron-repletion agent in this setting. Other novel oral iron preparations in development for IDA in patients with CKD include ferric maltol, which is approved in Europe and the United States for IDA in adult patients, and sucrosomial iron, which has been evaluated in IDA associated with CKD and several other clinical settings.
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90
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Kshirsagar AV, Li X. Long-Term Risks of Intravenous Iron in End-Stage Renal Disease Patients. Adv Chronic Kidney Dis 2019; 26:292-297. [PMID: 31477259 DOI: 10.1053/j.ackd.2019.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023]
Abstract
Patients with end-stage renal disease on dialysis commonly receive intravenous iron to treat anemia along with erythropoiesis-stimulating agents. While studies of intravenous iron have demonstrated efficacy in raising hemoglobin, the quantity of administered intravenous iron has raised concerns about iron overload leading to long-term toxicities. The goal of this review is to understand recent trends in intravenous iron use, potential mechanisms of iron toxicity, and to evaluate the available evidence in the literature for potential long-term cardiovascular and infectious complications. We include findings from the recently published landmark clinical trial of intravenous iron for patients receiving hemodialysis to contextualize treatment recommendations.
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91
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Intravenous iron versus oral iron or observation for gastrointestinal malignancies: a systematic review. Eur J Gastroenterol Hepatol 2019; 31:799-808. [PMID: 31082997 DOI: 10.1097/meg.0000000000001433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anemia is a common condition in patients with gastrointestinal cancer. Current evidence for the use of intravenous compared with oral iron in this clinical setting is inconclusive. A systematic review was performed to assess evidence on the efficacy of intravenous iron versus oral/observation in gastrointestinal cancer patients in the preoperative and postoperative setting. MATERIALS AND METHODS We searched Medline and Embase from inception until December 2017 with no language restrictions. Outcomes included hemoglobin response, red blood cell transfusion, and adverse events. Screening, data abstraction, and risk of bias appraisal were performed by two independent reviewers. The risk of bias was assessed using the Cochrane tools for randomized and nonrandomized studies. RESULTS A total of 10 studies (three randomized-controlled trials and seven nonrandomized studies) were included. Of the six preoperative studies, five reported that hemoglobin was significantly higher in the intravenous group compared with oral iron/observation. Among the four postoperative studies, three studies suggested that hemoglobin was significantly higher in the intravenous group compared with oral iron/observation. The overall risk of bias for all randomized-controlled trials was low. Quality assessments for nonrandomized studies found the risk of bias to be moderate for four studies and critical for three studies. CONCLUSION Despite the limitations of the current body of evidence, there is a likely benefit to the use of intravenous iron in this patient population. Further confirmatory research is needed to draw empirical conclusions.
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92
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Huang CW, Lee MJ, Wang LJ, Lee PT, Tu YK, Hsu CW, Lin PY. Comparative efficacy and acceptability of treatments for restless legs syndrome in end-stage renal disease: a systematic review and network meta-analysis. Nephrol Dial Transplant 2019; 35:1609-1618. [DOI: 10.1093/ndt/gfz097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients and impairs health and quality of life significantly. However, the optimal treatment of RLS in ESRD patients is uncertain and less studied compared with idiopathic RLS patients.
Methods
We conducted a systematic review and network meta-analysis to compare the efficacy and acceptability of treatments for RLS in ESRD patients. Randomized controlled trials (RCTs) by February 2019 in the PubMed, Cochrane Library, Embase and ClinicalTrials.gov were reviewed. RLS severity reduction was treated as treatment efficacy, and adverse events were treated as acceptable. Both outcomes were appraised using a random effects model expressed as standardized mean differences and odds ratios with 95% confidence intervals (CIs), respectively, and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to obtain a hierarchy of interventions.
Results
A total of 12 RCTs were included, comprising 9 interventions and 498 participants. All the interventions significantly improved RLS severity without critical side effects compared with placebo. Gabapentin achieved the greatest decrease of RLS severity [standardized mean difference (SMD) = 1.95, 95% CI 0.81–3.09 (SUCRA: 79.3%)], despite its frequent adverse events [SMD = 0.18, 95% CI 0.02–1.50 (19.9%)]. The combination therapy of exercise plus dopamine agonist had better efficacy [SMD = 1.60, 95% CI 0.08–3.12 (59.8%)] and acceptability [SMD = 1.41, 95% CI 0.01–142.53 (63.9%)] compared with that of vitamin C plus vitamin E [SMD = 1.50, 95% CI 0.47–2.54 (56.6%); SMD = 0.32, 95% CI 0.04–2.86 (32.5%)].
Conclusions
This network meta-analysis supports that gabapentin is the most effective treatment for RLS in ESRD patients. Exercise plus dopamine agonist is a favorable combination therapy concerning side effects. Future large RCTs with long-term treatment outcomes are necessary.
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Affiliation(s)
- Chien-Wei Huang
- Department of Medicine, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Min-Jing Lee
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Liang-Jen Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Tsang Lee
- Department of Medicine, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Abstract
Chronic kidney disease (CKD) is a major cause of morbidity and premature mortality and represents a significant global public health issue. Underlying this burden are the many complications of CKD, including mineral and bone disorders, anemia, and accelerated cardiovascular disease. Hyperphosphatemia and elevated levels of fibroblast growth factor 23 (FGF23) have been identified as key independent risk factors for the adverse cardiovascular outcomes that frequently occur in patients with CKD. Auryxia® (ferric citrate; Keryx Biopharmaceuticals, Inc., Boston, MA, USA) is an iron-based compound with distinctive chemical characteristics and a mechanism of action that render it dually effective as a therapy in patients with CKD; it has been approved as a phosphate binder for the control of serum phosphate levels in adult CKD patients treated with dialysis and as an iron replacement product for the treatment of iron deficiency anemia in adult CKD patients not treated with dialysis. This review focuses on Auryxia, its mechanism of action, and the clinical attributes that differentiate it from other, non-pharmaceutical-grade, commercially available forms of ferric citrate and from other commonly used phosphate binder and iron supplement therapies for patients with CKD. Consistent with the chemistry and mechanism of action of Auryxia, multiple clinical studies have demonstrated its efficacy in both lowering serum phosphate levels and improving iron parameters in patients with CKD. Levels of FGF23 decrease significantly with Auryxia treatment, but the effects associated with the cardiovascular system remain to be evaluated in longer-term studies.
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Affiliation(s)
- Tomas Ganz
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- CHS 47-200J, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Ave., Los Angeles, CA, 90095, USA.
- CHS 47-200J, Department of Pathology, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Ave., Los Angeles, CA, 90095, USA.
| | - Avi Bino
- Institute of Chemistry, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Isidro B Salusky
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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94
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Bohlius J, Bohlke K, Castelli R, Djulbegovic B, Lustberg MB, Martino M, Mountzios G, Peswani N, Porter L, Tanaka TN, Trifirò G, Yang H, Lazo-Langner A. Management of Cancer-Associated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update. J Clin Oncol 2019; 37:1336-1351. [DOI: 10.1200/jco.18.02142] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited. RECOMMENDATIONS ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines .
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | - Massimo Martino
- Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | | | | | | | | | | | - Hushan Yang
- Thomas Jefferson University, Philadelphia, PA
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95
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Treatment of iron deficiency in patients with chronic kidney disease: A prospective observational study of iron isomaltoside (NIMO Scandinavia)
. Clin Nephrol 2019; 91:246-253. [PMID: 30614439 PMCID: PMC6434427 DOI: 10.5414/cn109474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2019] [Indexed: 11/18/2022] Open
Abstract
Aims: Iron deficiency is common in patients with chronic kidney disease (CKD). Appropriate iron substitution is critical and intravenous iron is an established therapy for these patients. The objective of this study was to assess treatment routine, effectiveness, and safety of iron isomaltoside (Monofer®, Pharmacosmos A/S, Holbaek, Denmark) in CKD patients in clinical practice. Materials and methods: This was a prospective observational study conducted in predialysis CKD patients treated with iron isomaltoside according to the product label and to routine clinical care. Results: The study included 108 patients with predialysis CKD: 22 were in stage 2 – 3, 41 in stage 4, and 45 in stage 5. The mean (standard deviation) age was 67 (15) years, and 55% of patients were male. The majority of patients (65%) received one iron isomaltoside treatment. In patients with a baseline Hb < 10 g/dL, the mean dose of iron isomaltoside in the study was lower than the estimated total iron requirement (567 mg versus 921 mg). A treatment response of Hb ≥ 1 g/dL was achieved in 16/28 (57%) of patients, and the mean post-treatment Hb level was 10.5 g/dL. The probability of retreatment did not correlate with dose, but no dose administered was > 1,000 mg. There were no serious adverse drug reactions. One nonserious adverse drug reaction – injection site discoloration – was reported, and the patient had an uneventful recovery. Conclusion: Iron isomaltoside shows a good effectiveness and safety profile in predialysis CKD patients. However, some patients did not receive adequate iron doses to allow for optimal correction of their iron deficiency anemia.
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96
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Bohlius J, Bohlke K, Castelli R, Djulbegovic B, Lustberg MB, Martino M, Mountzios G, Peswani N, Porter L, Tanaka TN, Trifirò G, Yang H, Lazo-Langner A. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update. Blood Adv 2019; 3:1197-1210. [PMID: 30971397 PMCID: PMC6482353 DOI: 10.1182/bloodadvances.2018030387] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/28/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To update the American Society of Clinical Oncology (ASCO)/American Society of Hematology (ASH) recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs in patients with cancer published from January 31, 2010, through May 14, 2018. For biosimilar ESAs, the literature search was expanded to include meta-analyses and RCTs in patients with cancer or chronic kidney disease and cohort studies in patients with cancer due to limited RCT evidence in the cancer setting. ASCO and ASH convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The primary literature review included 15 meta-analyses of RCTs and two RCTs. A growing body of evidence suggests that adding iron to treatment with an ESA may improve hematopoietic response and reduce the likelihood of RBC transfusion. The biosimilar literature review suggested that biosimilars of epoetin alfa have similar efficacy and safety to reference products, although evidence in cancer remains limited. RECOMMENDATIONS ESAs (including biosimilars) may be offered to patients with chemotherapy-associated anemia whose cancer treatment is not curative in intent and whose hemoglobin has declined to < 10 g/dL. RBC transfusion is also an option. With the exception of selected patients with myelodysplastic syndromes, ESAs should not be offered to most patients with nonchemotherapy-associated anemia. During ESA treatment, hemoglobin may be increased to the lowest concentration needed to avoid transfusions. Iron replacement may be used to improve hemoglobin response and reduce RBC transfusions for patients receiving ESA with or without iron deficiency. Additional information is available at www.asco.org/supportive-care-guidelines and www.hematology.org/guidelines.
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Affiliation(s)
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | - Massimo Martino
- Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | | | | | | | | | | | - Hushan Yang
- Thomas Jefferson University, Philadelphia, PA; and
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97
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Gafter-Gvili A, Gafter U. Posttransplantation Anemia in Kidney Transplant Recipients. Acta Haematol 2019; 142:37-43. [PMID: 30970356 DOI: 10.1159/000496140] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 12/11/2018] [Indexed: 11/19/2022]
Abstract
Posttransplantation anemia (PTA) is common among kidney transplant patients. Early PTA is usually defined as anemia which develops up to 6 months after transplantation, and late PTA is defined as anemia which develops after 6 months. There are multiple causes, with iron deficiency being the major contributor. The occurrence of late PTA has been associated with impaired graft function. Early PTA has been shown to be a predictor of late PTA. PTA is associated with reduced mortality, reduced graft survival, and a decline in GFR. The association with mortality is related to the severity of the anemia and to specific causes of anemia. Treatment of PTA should probably begin as soon as possible after kidney transplantation. The optimal target hemoglobin level in kidney transplant recipients with anemia is higher than recommended in chronic kidney disease and should probably be up to 12.5-13 g/dL. In order to achieve this target, appropriate treatment with erythropoiesis-stimulating agents (ESA) and iron is indicated.
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Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine A, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel,
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Uzi Gafter
- Nephrology and Transplantation Immunology Laboratory, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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98
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Gafter-Gvili A, Schechter A, Rozen-Zvi B. Iron Deficiency Anemia in Chronic Kidney Disease. Acta Haematol 2019; 142:44-50. [PMID: 30970355 DOI: 10.1159/000496492] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/02/2019] [Indexed: 12/17/2022]
Abstract
Iron deficiency anemia is a common complication of chronic kidney disease (CKD). CKD patients suffer from both absolute and functional iron deficiency. Absolute iron deficiency is defined by severely reduced or absent iron stores, while functional iron deficiency is defined by adequate iron stores but insufficient iron availability for incorporation into erythroid precursors. This is due to increased levels of hepcidin. Anemia in CKD is associated with an increased risk of morbidity and mortality. The association between anemia and mortality may be related to the severity of anemia. All CKD patients should be screened for anemia during the initial evaluation for CKD. Criteria used to define iron deficiency are different among CKD compared to normal renal function. Among CKD patients, absolute iron deficiency is defined when the transferrin saturation (TSAT) is ≤20% and the serum ferritin concentration is ≤100 ng/mL among predialysis and peritoneal dialysis patients or ≤200 ng/mL among hemodialysis patients. Functional iron deficiency, also known as iron-restricted erythropoiesis, is characterized by TSAT ≤20% and elevated ferritin levels. Iron supplementation is recommended for all CKD patients with anemia. There is general agreement according to guidelines that intravenous (i.v.) iron supplementation is the preferred method for CKD patients on dialysis (CKD stage 5D) and either i.v. or oral iron is recommended for patients with CKD ND (CKD stages 3-5). In this review we discuss the evidence base for these recommendations.
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Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine A, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel,
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Amir Schechter
- Department of Medicine A, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Benaya Rozen-Zvi
- Nephrology and Hypertension Unit, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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99
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Wilson JAS, Tran J, Veith A, Landry D, Neville H, Kelly C, Soroka S, West K. Medication Reimbursement Model and Cost Savings in a Canadian Ambulatory Hemodialysis Program. Can J Hosp Pharm 2019; 72:155-159. [PMID: 31036978 PMCID: PMC6476575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Jo-Anne S Wilson
- , BScPharm, ACPR, PharmD, is with the College of Pharmacy, Faculty of Health, Dalhousie University, and the Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Jaclyn Tran
- , BScPharm, ACPR, is with the Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Annette Veith
- , RPhT, is with the Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - David Landry
- , BSc, MN, RN-NP, is with the Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Heather Neville
- , BScPharm, MSc, FCSHP, is with the Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Cindy Kelly
- , RN, BScN, is with the Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Steven Soroka
- , MD, MSc, FRCPC, is with the Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, and the Division of Nephrology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Kenneth West
- , MD, FRCPC, is with the Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia
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100
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Diebold M, Kistler AD. Evaluation of iron stores in hemodialysis patients on maintenance ferric Carboxymaltose dosing. BMC Nephrol 2019; 20:76. [PMID: 30823916 PMCID: PMC6397449 DOI: 10.1186/s12882-019-1263-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/21/2019] [Indexed: 02/07/2023] Open
Abstract
Background Iron is administered intravenously (IV) to many dialysis patients at regular intervals and iron stores are evaluated through periodic measurements of ferritin and transferrin saturation (TSAT). In patients without kidney diseases, large single doses of IV iron lead to a transient rise in serum ferritin that does not reflect iron stores. It is not known whether and to what extent smaller IV iron doses used to maintain adequate stores in hemodialysis patients lead to transient spurious elevations of ferritin and TSAT. Methods Ferritin and TSAT were serially determined over four weeks after the administration of ferric carboxymaltose (FCM) in hemodialysis patients on a stable maintenance FCM dosing regimen of 100 mg or 200 mg every four weeks. Results Ferritin values increased by 113 ± 72.2 μg/l (P < 0.001) from baseline to the peak value and remained significantly elevated until two weeks after the administration of 100 mg FCM (n = 19). After the administration of 200 mg FCM (n = 12), ferritin values increased by 188.5 ± 67.56 μg/l (P < 0.001) and remained significantly elevated by the end of week three. TSAT values increased by 12.0 ± 9.7% (P < 0.001) and 23.1 ± 20.4% (P = 0.002) in patients receiving 100 or 200 mg FCM, respectively, and returned to baseline within four days. Conclusions IV administration of FCM at doses of 100 or 200 mg in hemodialysis patients leads to dose-dependent transient ferritin elevations of extended duration. Temporal coordination of blood sampling for iron status evaluation with the maintenance IV iron dosing schedule is advisable. Trial registration ISRCTN12825165 (retrospectively registered 01/02/2019). Electronic supplementary material The online version of this article (10.1186/s12882-019-1263-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Diebold
- Division of Nephrology, Department of Medicine, Cantonal Hospital Frauenfeld, Pfaffenholzstrasse 4, 8501, Frauenfeld, Switzerland
| | - Andreas D Kistler
- Division of Nephrology, Department of Medicine, Cantonal Hospital Frauenfeld, Pfaffenholzstrasse 4, 8501, Frauenfeld, Switzerland.
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