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Sharma S, Pereira RC, Nemeth E, Hanudel MR, Ix JH, Salusky IB, Ganz T. Utility of Blood Biomarkers to Predict Marrow Iron Stores in Children. Clin J Am Soc Nephrol 2024; 19:860-868. [PMID: 38687125 PMCID: PMC11254016 DOI: 10.2215/cjn.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/24/2024] [Indexed: 05/02/2024]
Abstract
Key Points Serum ferritin was the strongest independent correlate of greater marrow iron stores in children with kidney failure supported by dialysis. Compared with current clinical guideline-based cutoffs for iron deficiency, ferritin outperforms these cut points for stainable marrow iron stores. Background Iron deficiency is common in children with kidney failure, but current guidelines are based on biomarkers of iron stores that may be influenced by inflammation. This is the first study that examined which serum iron indices were associated with stainable marrow iron stores (the gold standard) in this population with kidney failure who underwent bone biopsies. Methods This cross-sectional study enrolled 71 clinically stable children and young adults receiving dialysis who underwent bone biopsy for CKD-mineral bone disorder between 2007 and 2011. Bone biopsies were stained with Perls Prussian blue and independently interpreted by a pathologist blinded to participants' iron parameters and clinical status. Marrow staining was scored absent versus present to facilitate receiver operator curve (ROC) analysis. In ROC analysis, the ability of serum ferritin to detect stainable marrow iron stores was compared with that of transferrin saturation (TSAT), serum hepcidin, and clinical guideline-based iron deficiency cutoffs for serum iron, TSAT, and their combinations. Results The mean age was 17.2±4.4 years (range 2–28), and 30% of patients were female. Median dialysis vintage was 1.2 (interquartile range, 0.7–2.0) years, and 56% were supported by peritoneal dialysis. Mean hemoglobin was 12.4±1.7 g/dl, and 35% were receiving iron supplementation at the time of biopsy. On the basis of the gold standard of depleted marrow iron stores, 46.5% of patients were iron deficient. As an indicator of marrow iron staining, serum ferritin provided a larger area under the ROC curve than serum hepcidin, TSAT, or clinical guideline-based evaluation of TSAT+ferritin. Conclusions In this cohort of children and young adults with kidney failure, serum ferritin provided the best indication of stainable marrow iron stores, followed by TSAT.
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Affiliation(s)
- Shilpa Sharma
- Department of Medicine, David Geffen School of Medicine at UCLA, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Renata C. Pereira
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Elizabeta Nemeth
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mark R. Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Isidro B. Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Tomas Ganz
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Singh AT, Yen TE, Mothi SS, Waikar SS, Mc Causland FR. Associations of Iron Sucrose and Intradialytic Blood Pressure. Am J Kidney Dis 2023; 81:647-654. [PMID: 36587889 PMCID: PMC10205679 DOI: 10.1053/j.ajkd.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/02/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Intradialytic hypotension and intradialytic hypertension are associated with morbidity and mortality in hemodialysis (HD). Many factors can contribute to intra-HD blood pressure (BP) changes, such as drugs with vasoactive properties that can destabilize an already tenuous BP. Intravenous iron sucrose is commonly administered to correct iron deficiency; however, its reported associations with altered hemodynamics have not been consistent. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 950 outpatients receiving maintenance HD. EXPOSURE Iron sucrose administered during HD. OUTCOME Intradialytic hypotension, intradialytic hypertension, systolic blood pressure parameters. ANALYTICAL APPROACH Unadjusted and adjusted Poisson and linear repeated measures regression models. RESULTS The mean age of patients included in the study was 53±22 years, 43% were female, and 38% were Black. Mean pre-HD SBP was 152±26 (SD) mm Hg. At baseline, the patients who received higher doses of iron sucrose tended to have diabetes, have longer HD sessions, and have a higher frequency of erythropoiesis-stimulating agent use, compared with those who did not receive iron sucrose. In adjusted models, higher doses of iron sucrose were associated with an 11% lower rate of intradialytic hypotension (incidence rate ratio [IRR] for iron sucrose≥100mg vs 0 mg, 0.89 [95% CI, 0.85-0.94]). In adjusted analyses, the administration of higher doses of iron sucrose during HD was associated with intradialytic hypertension (IRR for iron sucrose≥100mg vs 0 mg, 1.07 [95% CI, 1.04-1.10]). LIMITATIONS Nonavailability of the precise iron sucrose formulation (volume), laboratory data for each HD session, and outpatient medications. Objective measures of volume status, home medications, and symptom data were not recorded in this study. CONCLUSIONS We observed an independent association of intravenous iron sucrose administration during HD with a lower risk of intradialytic hypotension and higher risk of intradialytic hypertension. Future studies to better understand the mechanisms underlying these associations are warranted. PLAIN-LANGUAGE SUMMARY Intradialytic hypotension and intradialytic hypertension are common among patients on hemodialysis, and they are associated with morbidity and mortality. Although many factors may contribute to these risks, medications administered during hemodialysis play an important role. We studied the significance of the intravenous iron sucrose used to treat iron deficiency and the impact it may have on blood pressure during dialysis. In our study of 950 outpatient hemodialysis patients, we observed that administration of iron sucrose was associated with higher systolic blood pressure (during and after hemodialysis sessions) as well as a lower risk of intradialytic hypotension. We also observed that higher doses of iron sucrose are associated with the development of intradialytic hypertension.
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Affiliation(s)
- Anika T Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts.
| | - Timothy E Yen
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
| | | | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, School of Medicine, and Boston Medical Center, Boston University, Boston, Massachusetts
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Medical School, Boston, Massachusetts
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Bielesz B, Lorenz M, Monteforte R, Prikoszovich T, Gabriel M, Wolzt M, Gleiss A, Hörl WH, Sunder-Plassmann G. Comparison of Iron Dosing Strategies in Patients Undergoing Long-Term Hemodialysis: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:1512-1521. [PMID: 34470831 PMCID: PMC8499011 DOI: 10.2215/cjn.03850321] [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: 03/18/2021] [Accepted: 08/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Whether iron supplementation in patients on hemodialysis could be delivered by less frequent but higher single doses compared with the currently more common higher-frequency schedules of lower single iron doses is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We carried out an open-label, randomized, controlled noninferiority trial over 40 weeks in patients on prevalent hemodialysis (n=142). We administered in total 2 g iron as 100 mg iron sucrose biweekly in a continuous (20 × 100 mg) fashion or 500 mg ferric carboxymaltose every 10 weeks in a periodic (4 × 500 mg) fashion. The primary end point was the change in hemoglobin at week 40 from baseline with a noninferiority margin of -0.8 g/dl. Secondary end points were changes in ferritin, transferrin, transferrin saturation, and erythropoiesis-stimulating agent use. RESULTS In total, 108 patients completed the study. At 40 weeks, hemoglobin changed by -0.27 g/dl (95% confidence interval, -0.64 to 0.09) in the iron sucrose arm and by -0.74 g/dl (95% confidence interval, -1.1 to -0.39) in the ferric carboxymaltose arm compared with baseline. Noninferiority was not established in the per-protocol population as hemoglobin changes compared with baseline differed by -0.47 g/dl (95% confidence interval, -0.95 to 0.01) in the ferric carboxymaltose arm compared with the iron sucrose arm. Proportional changes from baseline to week 40 differed by -31% (98.3% confidence interval, -52 to -0.1) for ferritin, by 1% (98.3% confidence interval, -7 to 10) for transferrin, and by -27% (98.3% confidence interval, -39 to -13) for transferrin saturation in the ferric carboxymaltose arm compared with the iron sucrose arm. Erythropoiesis-stimulating agent dosing did not differ between groups. The overall number of adverse events was similar; however, more infections were observed in the iron sucrose arm. CONCLUSIONS An equal cumulative dose of ferric carboxymaltose administered less frequently did not meet noninferiority for maintaining hemoglobin levels compared with iron sucrose administered more frequently. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Comparison Study of Two Iron Compounds for Treatment of Anemia in Hemodialysis Patients (COPEFER), NCT02198495.
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Affiliation(s)
- Bernhard Bielesz
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Rossella Monteforte
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Institute of Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Walter H. Hörl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Low-Dose Maintenance Intravenous Iron Therapy Can Prevent Anemia in Children with End-Stage Renal Disease Undergoing Chronic Hemodialysis. Int J Nephrol 2020; 2020:3067453. [PMID: 32566294 PMCID: PMC7284959 DOI: 10.1155/2020/3067453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/16/2020] [Indexed: 01/16/2023] Open
Abstract
Iron deficiency anemia is common in children with end-stage renal disease (ESRD) on long-term hemodialysis receiving erythropoiesis-stimulating agents. One approach to maintain the iron profile and hemoglobin levels is maintenance therapy with regular low doses of intravenous (IV) iron after initial iron repletion therapy; however, evidence for the benefits of this approach is lacking. This study evaluated the effect of IV iron maintenance therapy on anemia in children on regular hemodialysis. This retrospective cohort study included 41 pediatric ESRD patients with normal hemoglobin and iron status who underwent regular hemodialysis at the Pediatric Dialysis Unit of Cipto Mangunkusumo Hospital, Indonesia, between January 2015 and April 2019. Among these, 21 received IV iron maintenance therapy with two doses of 2 mg/kg of IV iron sucrose every 2 weeks (the treatment group) and 20 did not (the comparison group). Changes in hemoglobin and transferrin saturation were assessed after 6 weeks of observation and compared between the two groups. There was a significant reduction in the mean hemoglobin level compared with the baseline level in the comparison group (21 g/L; 95% CI, 9.3–33 g/L; p=0.001) but not in the treatment group (0.7 g/L; 95% CI, −6.6–8 g/L; p=0.84). The risk of anemia was lower in the treatment group (relative risk = 0.42; 95% CI, 0.22–0.79; p=0.003). Although majority of the patients had high baseline ferritin level, this study indicates that in our setting, ferritin may not be a reliable parameter to review the iron status, as it can be affected by chronic inflammation. Hence, the decision to start IV iron maintenance therapy in patients with hyperferritinemia should consider the patient's clinical condition and morbidity. To conclude, the coadministration of IV iron maintenance therapy is beneficial for maintaining hemoglobin levels and preventing anemia in children with ESRD who are undergoing regular hemodialysis, have achieved the target hemoglobin levels, and have normal iron status.
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Mattiello V, Schmugge M, Hengartner H, von der Weid N, Renella R. Diagnosis and management of iron deficiency in children with or without anemia: consensus recommendations of the SPOG Pediatric Hematology Working Group. Eur J Pediatr 2020; 179:527-545. [PMID: 32020331 DOI: 10.1007/s00431-020-03597-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 11/26/2022]
Abstract
Iron deficiency is the most prevalent nutritional deficiency affecting children and adolescents worldwide. A consistent body of epidemiological data demonstrates an increased incidence of iron deficiency at three timepoints: in the neonatal period, in preschool children, and in adolescents, where it particularly affects females.Conclusion: This narrative review focuses on the most suggestive symptoms of iron deficiency in childhood, describes the diagnostic procedures in situations with or without anemia, and provides Swiss expert-based management recommendations for the pediatric context.What is Known:• Iron deficiency (ID) is one of the most common challenges faced by pediatricians.• Significant progress in the diagnosis and therapy of ID has been made over the last decade.What is New:• Our expert panel provides ID management recommendations based on the best available evidence.• They include strategies for ID diagnosis and therapy, both oral and intravenous.
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Affiliation(s)
- Veneranda Mattiello
- Department "Woman-Mother-Child and Adolescent", Pediatric Hematology-Oncology Unit, Division of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Markus Schmugge
- Division of Pediatric Hematology, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Heinz Hengartner
- Pediatric Hematology-Oncology Unit, Children's Hospital of Sankt Gallen, Sankt Gallen, Switzerland
| | - Nicolas von der Weid
- Pediatric Hematology-Oncology Department, University Children's Hospital and University of Basel, Basel, Switzerland
| | - Raffaele Renella
- Department "Woman-Mother-Child", Pediatric Hematology-Oncology Unit, Division of Pediatrics, Lausanne University Hospital and University of Lausanne, Vaudois, BH11, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Wu S, Zhang H, Wang J, Li X, Gao X, Fang Z, Qu J, Wu Y, Ren Y, Rui W, Zhang J, Yao Z. Iron Sucrose as MRI Contrast Agent in Ischemic Stroke Model. J Magn Reson Imaging 2020; 52:836-849. [PMID: 32112623 DOI: 10.1002/jmri.27109] [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: 11/27/2019] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Despite the growing concern about the safety of gadolinium-based contrast agents (GBCAs), they are still the most commonly used. Ferumoxytol, as an off-label alternative MRI contrast agent, cannot be administered by a rapid bolus for dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI). PURPOSE To assess the feasibility of iron sucrose (IS) as a contrast agent for MR angiography (MRA) and DSC-PWI. STUDY TYPE Prospective animal model. ANIMAL MODEL Thirty-six normal rats (16 for MRA, 20 for biocompability tests) and 36 occlusion of the middle cerebral artery (MCAO) model rats. FIELD STRENGTH/SEQUENCE 3.0T; head and neck angiography, using a fast spoiled gradient-recalled-echo (FSPGR) sequence and DSC-MRI using echo planar imaging(EPI) sequence. ASSESSMENT MRA was performed on normal rats to examine the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of different doses of IS. DSC-PWI was performed on MCAO rats at 0, 24, 48, and 72 hours postreperfusion to investigate the lesion detectability of IS. Arterial spin labeling (ASL) and DSC-PWI enhanced by GBCAs were conducted on MCAO rats as controls. STATISTICAL TESTS Kruskal-Wallis test was used to compare qualitative assessment. One-way analysis of variance (ANOVA) was used to compare the parametric data. Pearson's r values were evaluated between relative cerebral blood flow(rCBF)-ASL, rCBF-DSCIS , and rCBF obtained from DSC-PWI enhanced by GBCA. RESULTS The mean SNR and CNR of the common carotid artery at doses of 10 mg Fe/kg of IS were comparable with the standard dose of GBCAs (SNR: 68.04 ± 12.55 vs. 67.72 ± 14.66; CNR: 23.78 ± 7.21vs. 21.63 ± 6.83). In MCAO rat models, rCBF and relative cerebral blood volume (rCBV) of ipsilateral striatum declined (0.72 ± 0.14, 0.86 ± 0.11) with prolonged relative mean transit time (rMTT) and relative time-to-peak (rTTP) (1.27 ± 0.24, 1.07 ± 0.03) following occlusion. Hyperperfusion was observed in all rats at 48 and 72 hours postreperfusion, in 4/6 rats at 24 hours postreperfusion for IS-mediated DSC-PWI. DATA CONCLUSION IS may be an effective contrast agent for both MRA and DSC-PWI in ischemic stroke models. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 1 J. Magn. Reson. Imaging 2020;52:836-849.
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Affiliation(s)
- Shiman Wu
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua Zhang
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Wang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyan Li
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinyi Gao
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Ziwei Fang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianxun Qu
- GE Healthcare, MR research, Applied Science Lab, Shanghai, China
| | - Yue Wu
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan Ren
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenting Rui
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Junhai Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenwei Yao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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Moore JM, Krebs NF. Comment on: Micronutrient intake and biochemistry in adolescents adherent or nonadherent to supplements 5 years after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2019; 15:1503-1504. [PMID: 31466872 DOI: 10.1016/j.soard.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Jaime M Moore
- University of Colorado School of Medicine, Aurora, Colorado
| | - Nancy F Krebs
- University of Colorado School of Medicine, Aurora, Colorado
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Ferumoxytol for iron deficiency anemia in patients undergoing hemodialysis. The FACT randomized controlled trial
. Clin Nephrol 2019; 91:237-245. [PMID: 30802204 PMCID: PMC6434426 DOI: 10.5414/cn109512] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Patients with chronic kidney disease (CKD) undergoing dialysis often require intravenous iron for iron deficiency anemia (IDA). Materials and methods: The Ferumoxytol for Anemia of CKD Trial (FACT), a randomized, multicenter, open-label, phase 4 study, compared the long-term safety and efficacy of ferumoxytol with iron sucrose for the treatment of IDA in patients with CKD undergoing hemodialysis. Patients with IDA and CKD undergoing hemodialysis were randomized 2:1 to ferumoxytol 1.02 g (2 × 510 mg) or iron sucrose 1.0 g (10 × 100 mg) for a 5-week treatment period (TP). Over 11 months, patients underwent additional 5-week TPs whenever IDA (hemoglobin < 11.5 g/dL and transferrin saturation < 30%) was detected. The primary efficacy endpoint was mean change in hemoglobin from baseline to week 5 for each TP. Adverse events were recorded during the study. Results: Overall, 293 patients received ferumoxytol (n = 196) or iron sucrose (n = 97). Ferumoxytol was noninferior to iron sucrose regarding hemoglobin change from baseline to week 5. The mean change in hemoglobin in the ferumoxytol and iron sucrose groups was 0.5 and 0.4 g/dL, respectively, in TP 1 (least-squares mean difference, 0.13; 95% confidence interval, –0.11 to 0.36) and 0.6 and 0.3 g/dL, respectively, in TP 2 (0.30; 0.06 – 0.55). Treatment-related and serious adverse events were similar in both groups; no new safety signals emerged. Conclusion: Long-term administration of ferumoxytol has noninferior efficacy and a similar safety profile to iron sucrose when used to treat IDA in patients with CKD undergoing hemodialysis.
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Bhandari S, Pereira DIA, Chappell HF, Drakesmith H. Intravenous Irons: From Basic Science to Clinical Practice. Pharmaceuticals (Basel) 2018; 11:E82. [PMID: 30150598 PMCID: PMC6161004 DOI: 10.3390/ph11030082] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 02/07/2023] Open
Abstract
Iron is an essential trace mineral necessary for life, and iron deficiency anaemia (IDA) is one of the most common haematological problems worldwide, affecting a sixth of the global population. Principally linked to poverty, malnutrition and infection in developing countries, in Western countries the pathophysiology of IDA is primarily linked to blood loss, malabsorption and chronic disease. Oral iron replacement therapy is a simple, inexpensive treatment, but is limited by gastrointestinal side effects that are not inconsequential to some patients and are of minimal efficacy in others. Third generation intravenous (IV) iron therapies allow rapid and complete replacement dosing without the toxicity issues inherent with older iron preparations. Their characteristic, strongly-bound iron-carbohydrate complexes exist as colloidal suspensions of iron oxide nanoparticles with a polynuclear Fe(III)-oxyhydroxide/oxide core surrounded by a carbohydrate ligand. The physicochemical differences between the IV irons include mineral composition, crystalline structure, conformation, size and molecular weight, but the most important difference is the carbohydrate ligand, which influences complex stability, iron release and immunogenicity, and which is a unique feature of each drug. Recent studies have highlighted different adverse event profiles associated with third-generation IV irons that reflect their different structures. The increasing clinical evidence base has allayed safety concerns linked to older IV irons and widened their clinical use. This review considers the properties of the different IV irons, and how differences might impact current and future clinical practice.
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Affiliation(s)
- Sunil Bhandari
- Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Hull HU3 2JZ, UK.
| | - Dora I A Pereira
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK.
- MRC Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, Republic of Gambia.
| | - Helen F Chappell
- School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK.
| | - Hal Drakesmith
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Headington, Oxford OX3 9DS, UK.
- Haematology Theme Oxford Biomedical Research Centre, Oxford OX3 9DS, UK.
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Iron and trace minerals. Clin Nutr 2018; 37:2354-2359. [PMID: 30078716 DOI: 10.1016/j.clnu.2018.06.949] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/26/2022]
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Atkinson MA, Warady BA. Anemia in chronic kidney disease. Pediatr Nephrol 2018; 33:227-238. [PMID: 28412770 DOI: 10.1007/s00467-017-3663-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 12/12/2022]
Abstract
Anemia is common and associated with adverse outcomes in children with chronic kidney disease (CKD). Many factors contribute to declining hemoglobin as CKD progresses, but impaired production of erythropoietin by failing kidneys is a central cause. Hepcidin-mediated iron restriction also contributes to anemia by downregulating both intestinal iron absorption and release of stored iron for erythropoiesis. The core components of anemia management remain erythropoiesis-stimulating agents (ESA) and iron supplementation, but despite these therapies, a substantial number of children remain anemic. Although escalating ESA dose to target higher hemoglobin has been associated with adverse outcomes in adults, no trials have investigated this association in children, and maintaining hemoglobin levels in a narrow range with conservative ESA dosing is challenging. Judicious use of iron supplementation can enhance the response to ESAs, but the iron storage markers most commonly used in clinical practice have limitations in distinguishing which patients will benefit most from additional iron. Several novel anemia therapies, including hypoxia-inducible factor stabilizers, prolyl hydroxylase inhibitors, and dialysate-delivered iron supplements, have been developed and may offer options for alternative anemia management. However, the safety and efficacy of these agents in children with CKD has yet to be assessed.
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Affiliation(s)
- Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N. Wolfe St, Baltimore, MD, 21287, USA.
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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12
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Papadopoulos M, Patel D, Korologou-Linden R, Goto E, Soondrum K, Fell JME, Epstein J. Safety and efficacy of parenteral iron in children with inflammatory bowel disease. Br J Clin Pharmacol 2018; 84:694-699. [PMID: 29266387 DOI: 10.1111/bcp.13493] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 12/06/2017] [Accepted: 12/11/2017] [Indexed: 12/15/2022] Open
Abstract
AIMS Iron deficiency anaemia frequently complicates inflammatory bowel disease (IBD) in children and adults. Oral iron may exacerbate gastrointestinal symptoms and absorption may be insufficient in intestinal inflammation. Even where oral iron is successful, repletion of iron stores can be unacceptably slow. Intravenous iron compounds were in the past associated with serious adverse reactions and historically were considered a last resort in children. New generation preparations have a safer profile in adults, although reluctance to use them in children may persist, where safety data are lacking. We investigate the safety and efficacy of ferric carboxymaltose and iron sucrose in children. METHODS We retrospectively identified all children with IBD who received parenteral iron over a 38-month period in a single regional referral centre. Safety, tolerability and adverse events were established by case note review. Efficacy was assessed by change in haematinic indices pre- and post-treatment. RESULTS Forty-one children (18 male; median age 14 years, range 3-17) received a total of 104 iron infusions. Of these, 44% (18) had Crohn's disease; 56% (23) ulcerative colitis. Thirty-five received ferric carboxymaltose, seven iron sucrose and one both. Three children developed mild rash post infusion which resolved quickly with chlorphenamine. Mean increase in haemoglobin was 2.5 g dl-1 (0.3-5.8). Iron levels increased by a mean of 8.4 g dl-1 (1-25), transferrin saturation by 16.2% (2-47). Transferrin decreased by 0.84 g dl-1 (0.3-3.4). CONCLUSIONS New generation parenteral iron preparations are safe, well tolerated and efficacious in children with iron deficiency anaemia and IBD.
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Affiliation(s)
- Michael Papadopoulos
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Deepa Patel
- Department of Paediatric Pharmacy, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | | | - Eunice Goto
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Krishna Soondrum
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - John M E Fell
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
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Abstract
Optimal care of the pediatric end-stage renal disease (ESRD) patient on chronic dialysis is complex and requires multidisciplinary care as well as patient/caregiver involvement. The dialysis team, along with the family and patient, should all play a role in choosing the dialysis modality which best meets the patient's needs, taking into account special considerations and management issues that may be particularly pertinent to children who receive peritoneal dialysis or hemodialysis. Meticulous attention to dialysis adequacy in terms of solute and fluid removal, as well as to a variety of clinical manifestations of ESRD, including anemia, growth and nutrition, chronic kidney disease-mineral bone disorder, cardiovascular health, and neurocognitive development, is essential. This review highlights current recommendations and advances in the care of children on dialysis with a particular focus on preventive measures to minimize ESRD-associated morbidity and mortality. Advances in dialysis care and prevention of complications related to ESRD and dialysis have led to better survival for pediatric patients on dialysis.
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The Ferumoxytol for Anemia of CKD Trial (FACT)-a randomized controlled trial of repeated doses of ferumoxytol or iron sucrose in patients on hemodialysis: background and rationale. BMC Nephrol 2017; 18:117. [PMID: 28372549 PMCID: PMC5379516 DOI: 10.1186/s12882-017-0523-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/23/2017] [Indexed: 11/24/2022] Open
Abstract
Background Iron deficiency anemia (IDA) is a common manifestation of chronic kidney disease (CKD), affecting most patients on hemodialysis and imposing a substantial clinical burden. Treatment with iron supplementation increases hemoglobin levels and can reduce the severity of anemia in patients with CKD. While correcting anemia in these patients is an important therapeutic goal, there is a lack of long-term trials directly comparing intravenous iron therapies in patients with CKD receiving hemodialysis. Methods/Design The Ferumoxytol for Anemia of CKD Trial (FACT) is a 13-month, open-label, randomized, multicenter, international, prospective study with 2 substudies. Entry criteria for the main study include adults with IDA (defined as hemoglobin <11.5 g/dL [<115.0 g/L] and a transferrin saturation <30%), serum ferritin <800 ng/mL (<1798 pmol/L), and receiving hemodialysis for ≥3 months. Patients are randomized to receive ferumoxytol (1.02 g over 2 doses) or iron sucrose (1.0 g over 10 doses) during the initial 5-week treatment period. Those with persistent/recurrent IDA over the 11-month observation period will receive additional 5-week treatment periods, as appropriate. The primary efficacy endpoint of the main study is the mean change in hemoglobin from Baseline to Week 5 for each treatment period. The secondary efficacy endpoints include the mean change in transferrin saturation from Baseline to Week 5 and the proportion of patients with a hemoglobin increase of ≥1.0 g/dL at any time from Baseline to Week 5. Safety will be assessed through an examination of the adverse event profile over the course of the study. An “oxidative stress” substudy in approximately 100 patients will assess the effects of treatment on biomarkers of oxidative stress/inflammation during the initial 5-week treatment period, and a magnetic resonance imaging substudy in approximately 70 patients will assess the potential for iron deposition in target tissues over 24 months. Discussion FACT fulfills the need for a long-term comparative trial in patients with IDA and CKD receiving hemodialysis. The efficacy and safety results will provide useful information for guiding therapy in this population. Two hundred ninety-six patients have been enrolled, and completion of the main study is expected soon. Trial registration ClinicalTrials.gov identifier: NCT01227616 (registered October 22, 2010); EudraCT number: 2010-022133-28
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15
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Tong A, Samuel S, Zappitelli M, Dart A, Furth S, Eddy A, Groothoff J, Webb NJA, Yap HK, Bockenhauer D, Sinha A, Alexander SI, Goldstein SL, Gipson DS, Hanson CS, Evangelidis N, Crowe S, Harris T, Hemmelgarn BR, Manns B, Gill J, Tugwell P, Van Biesen W, Wheeler DC, Winkelmayer WC, Craig JC. Standardised Outcomes in Nephrology-Children and Adolescents (SONG-Kids): a protocol for establishing a core outcome set for children with chronic kidney disease. Trials 2016; 17:401. [PMID: 27519274 PMCID: PMC4982996 DOI: 10.1186/s13063-016-1528-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/26/2016] [Indexed: 01/03/2023] Open
Abstract
Background Children with chronic kidney disease (CKD), requiring dialysis or kidney transplantation, have a mortality rate of up to 30-fold higher than the general aged-matched population, and severely impaired quality of life. Symptoms such as fatigue and pain are prevalent and debilitating. Children with CKD are at risk of cognitive impairment, and poorer educational, vocational, and psychosocial outcomes compared with their well peers, which have consequences through to adulthood. Treatment regimens for children with CKD are long-term, complex, and highly intrusive. While many trials have been conducted to improve outcomes in children with CKD, the outcomes measured and reported are often not relevant to patients and clinicians, and are highly variable. These problems can diminish the value of trials as a means to improve the lives of children with CKD. The Standardised Outcomes in Nephrology—Children and Adolescents (SONG-Kids) study aims to develop a core outcome set for trials in children and adolescents with any stage of CKD that is based on the shared priorities of all stakeholders. Methods/Design SONG-Kids involves five phases: a systematic review to identify outcomes (both domains and measures) that have been reported in randomised controlled trials involving children aged up to 21 years with CKD; focus groups (using nominal group technique) with adolescent patients and caregivers of paediatric patients (all ages) to identify outcomes that are relevant and important to patients and their family and the reasons for their choices; semistructured key informant interviews with health professionals involved in the care of children with CKD to ascertain their views on establishing core outcomes in paediatric nephrology; an international three-round online Delphi survey with patients, caregivers, clinicians, researchers, policy-makers, and members from industry to develop consensus on important outcome domains; and a stakeholder workshop to review and finalise the set of core outcome domains for trials in children with CKD (including nondialysis-dependent, dialysis, and kidney transplantation). Discussion Establishing a core outcome set to be reported in all trials conducted in children with any stage of CKD will enhance the relevance, transparency, and impact of research to improve the lives of children and adolescents with CKD.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia. .,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
| | - Susan Samuel
- Department of Pediatrics, Section of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Pediatric Nephrology, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Allison Dart
- Department of Pediatrics and Child Health, The Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Susan Furth
- Departments of Pediatrics and Epidemiology, Perelman School of Medicine and Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Allison Eddy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jaap Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital AMC Academic Medical Center, Amsterdam, The Netherlands
| | - Nicholas J A Webb
- Department of Paediatric Nephrology and NIHR/Wellcome Trust Clinical Research Facility, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Detlef Bockenhauer
- UCL Centre for Nephrology and Great Ormond Street Hospital for Children NHS Foundation Trus, London, UK
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Debbie S Gipson
- Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
| | | | | | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Braden Manns
- Departments of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - John Gill
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
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Kuji T, Toya Y, Fujikawa T, Kakimoto-Shino M, Nishihara M, Shibata K, Tamura K, Hirawa N, Satta H, Kawata SI, Kouguchi N, Umemura S. Acceleration of iron utilization after intravenous iron administration during activated erythropoiesis in hemodialysis patients: a randomized study. Ther Apher Dial 2014; 19:131-7. [PMID: 25257861 DOI: 10.1111/1744-9987.12237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study aimed to evaluate the effect of different timings of iron administration during erythropoiesis activated by continuous erythropoietin receptor activator (CERA) on reticulocyte iron uptake in hemodialysis patients. In total, 110 patients were randomized to receive 40 mg intravenous elemental iron doses at all three hemodialysis sessions in the first week (IW1 group: n = 57) or in the third week (IW3 group: n = 53) after CERA administration. Following CERA administration at day 0, reticulocyte count increased, peaking at day 7. At days 7 and 14, the observed changes in Ret-He were higher in the IW1 group than in the IW3 group. Increases in total reticulocyte hemoglobin at day 7 were higher in the IW1 group than in the IW3 group. In contrast, there was only tendency toward greater total reticulocyte hemoglobin after iron administration in the third week in the IW3 group. Intravenous iron supplementation in the first week of CERA administration increases reticulocyte iron uptake; however, iron supplementation in the third week does not. The findings indicate that iron should be intravenously administered to increase the efficacy of CERA within 1 week of CERA administration during highly active erythropoiesis.
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Affiliation(s)
- Tadashi Kuji
- Yokodai Central Clinic, Yokohama, Kanagawa, Japan; Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine and School of Medicine, Yokohama, Kanagawa, Japan
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Warady BA, Silverstein DM. Management of anemia with erythropoietic-stimulating agents in children with chronic kidney disease. Pediatr Nephrol 2014; 29:1493-505. [PMID: 24005791 DOI: 10.1007/s00467-013-2557-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/29/2013] [Accepted: 06/20/2013] [Indexed: 11/28/2022]
Abstract
Anemia management is an important component of the care provided to children with chronic kidney disease (CKD) and influences both morbidity and mortality risk. The introduction of recombinant human erythropoietin to the treatment regimen three decades ago revolutionized the therapy and significantly decreased the need for repeated blood transfusions and exposure to associated risks. Recent data on the efficacy and complications associated with erythropoietic-stimulating agent (ESA) usage has, however, prompted a reassessment of treatment-related recommendations. This review will address these recommendations, in addition to describing pediatric outcomes associated with current ESAs and presenting information on alternative ESAs, many of which will likely soon be incorporated into clinical practice.
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Affiliation(s)
- Bradley A Warady
- Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA,
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Warady BA, Neu AM, Schaefer F. Optimal Care of the Infant, Child, and Adolescent on Dialysis: 2014 Update. Am J Kidney Dis 2014; 64:128-42. [DOI: 10.1053/j.ajkd.2014.01.430] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 01/28/2014] [Indexed: 12/18/2022]
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Weiner DE, Winkelmayer WC. Commentary on 'The DOPPS practice monitor for U.S. dialysis care: update on trends in anemia management 2 years into the bundle': iron(y) abounds 2 years later. Am J Kidney Dis 2014; 62:1217-20. [PMID: 24267389 DOI: 10.1053/j.ajkd.2013.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 11/11/2022]
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