Iron management during treatment with recombinant human erythropoietin in chronic renal failure

Effects of altitude and recombinant human erythropoietin on iron metabolism: a randomized controlled trial

Current markers of iron deficiency (ID), such as ferritin and hemoglobin, have shortcomings, and hepcidin and erythroferrone (ERFE) could be of clinical relevance in relation to early assessment of ID. Here, we evaluate whether exposure to altitude-induced hypoxia (2,320 m) alone, or in combination with recombinant human erythropoietin (rHuEPO) treatment, affects hepcidin and ERFE levels before alterations in routine ID biomarkers and stress erythropoiesis manifest. Two interventions were completed, each comprising a 4-wk baseline, a 4-wk intervention at either sea level or altitude, and a 4-wk follow-up. Participants (n = 39) were randomly assigned to 20 IU·kg body wt^-1 rHuEPO or placebo injections every second day for 3 wk during the two intervention periods. Venous blood was collected weekly. Altitude increased ERFE (P ≤ 0.001) with no changes in hepcidin or routine iron biomarkers, making ERFE of clinical relevance as an early marker of moderate hypoxia. rHuEPO treatment at sea level induced a similar pattern of changes in ERFE (P < 0.05) and hepcidin levels (P < 0.05), demonstrating the impact of accelerated erythropoiesis and not of other hypoxia-induced mechanisms. Compared with altitude alone, concurrent rHuEPO treatment and altitude exposure induced additive changes in hepcidin (P < 0.05) and ERFE (P ≤ 0.001) parallel with increases in hematocrit (P < 0.001), demonstrating a relevant range of both hepcidin and ERFE. A poor but significant correlation between hepcidin and ERFE was found (R² = 0.13, P < 0.001). The findings demonstrate that hepcidin and ERFE are more rapid biomarkers of changes in iron demands than routine iron markers. Finally, ERFE and hepcidin may be sensitive markers in an antidoping context.

Randomized cross-over study of adverse reactions and cost implications of intravenous push compared with infusion of iron dextran in hemodialysis patients

In many dialysis centers, iron dextran is administered by intravenous infusion rather than intravenous push (the method of administration recommended in the package insert) as a possible, but unproven, means to reduce side effects. This study was performed to determine whether there is a difference in adverse reactions between these two methods. Ten iron-deficient hemodialysis patients participated in a randomized, cross-over study of iron dextran 100 mg administered by intravenous push over 2 minutes (undiluted) or as a 30-minute intravenous infusion during the first hour of hemodialysis. Patients received a total of four doses (two by each method during four separate dialysis sessions). Blood pressure and heart rate were monitored pre-dose and at frequent intervals throughout the hemodialysis session following the dose. Patients completed adverse event surveys before and 60 minutes after the dose and prior to the next hemodialysis session. Blood pressure, heart rate, and survey data were analyzed using a Wilcoxon analysis (P </= 0.05 was considered significant). Seven patients received all four doses, two patients received only three doses (one due to missed hemodialysis session and one due to severe diarrhea possibly related to iron dextran), and one patient received only one dose (due to unstable clinical status). No differences in blood pressure, heart rate, or adverse events were observed between the two administration methods. A cost-minimization analysis was performed to compare the costs of each method of iron dextran administration. There were no differences in nursing time or number of syringes and needles used between the two methods. However, cost savings were observed with intravenous push administration because the intravenous tubing and intravenous piggyback were eliminated. Iron dextran can be administered by either intravenous push or intravenous infusion during the first hour of hemodialysis, with no significant differences between the two methods in terms of blood pressure or heart rate. Dialysis programs can minimize iron dextran administration costs by changing to the intravenous push method.

Recombinant human erythropoietin treatment of anemia in renal transplant patients

The rHuEpo effect on anemia in eight renal transplant patients (group A) with severe anemia (Hb 6.0-7.5 g/dL) and chronic graft failure (CGF) (sCr 281-794 mumol/L) was compared to the rHuEpo effect on anemia in predialysis (20 patients-group B) and hemodialysis patients (17 patients-group C) in order to examine the rHuEpo effect on anemia and graft failure progression, and to find out whether the response to therapy in these three patient groups differed. Although renal function impairment was similar in patients from group A and B, anemia was more severe in patients from group A. Serum immunoreactive erythropoietin levels were within normal limits for nonanemic persons, that is, inadequate for the level of anemia in all patients before therapy. Maintenance immunosuppression given after renal transplantation consisted of cyclosporine, azathioprine, and prednisone in standard doses. The startig rHuEpo dose of 150 U/kg/wk increased by 25 U/kg if the target Hb of 10.0 g/dL was not achieved at the end of a 4-week period. When target Hb was achieved, the rHuEpo dose was regularly adjusted to maintain Hb of 10.0 g/dL. Most patients from group A and group C were polytransfused before rHuEpo therapy and consequently with iron overload so that only some patients from these groups and all predialysis patients needed iron supplementation given orally. Anemia improved in all patients with 2 to 10 weeks of treatment. Mean rHuEpo doses for the first 2 months were similar in three studied groups, but the patients with the lowest initial hemoglobin values responded better to rHuEpo therapy. The rate of Hb increase during the initial phase of therapy was significantly higher in patients from group A and B comparing to patients from group C, indicating the importance of residual renal function for rHuEpo effect on anemia. Progression of CGF expressed by the slope of l/sCr vs. time did not change in either patients from group A or in predialysis patients. It could be concluded that rHuEpo therapy improved anemia in transplant patients as in predialysis and hemodialysis patients. Anemia improvement by rHuEpo did not accelerate the progression of graft function.