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Shrestha P, Paul S, Sumida K, Thomas F, Surbhi S, Naser AM, Streja E, Rhee CM, Kalantar-Zadeh K, Kovesdy CP. Association of iron therapy with incidence of chronic kidney disease. Eur J Haematol 2023; 111:872-880. [PMID: 37668586 DOI: 10.1111/ejh.14091] [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: 05/04/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE We investigated the association of oral iron replacement with the incidence of chronic kidney disease (CKD) in a population with normal kidney function to study the effects of iron replacement on the development of new onset CKD. METHODS In a national cohort of US Veterans with no pre-existing CKD, we identified 33 894 incident new users of oral iron replacement and a comparable group of 112 780 patients who did not receive any iron replacement during 2004-2018. We examined the association of oral iron replacement versus no iron replacement with the incidence of eGFR <60 mL/min/1.73 m2 and the incidence of urine albumin creatinine ratio (UACR) ≥30 mg/g in competing risk regressions and in Cox models. We used propensity score weighing to account for differences in key baseline characteristics associated with the use of oral iron replacement. RESULTS In the cohort of 146 674 patients, a total of 18 547 (13%) patients experienced incident eGFR <60 mL/min/1.73 m2 , and 16 117 patients (11%) experienced new onset UACR ≥30 mg/g. Oral iron replacement was associated with significantly higher risk of incident eGFR <60 mL/min/1.73 m2 (subhazard ratio, 95% confidence interval [CI]: 1.3 [1.22-1.38], p < .001) and incident albuminuria (subhazard ratio, 95% CI: 1.14 [1.07-1.22], p < .001). CONCLUSION Oral iron replacement is associated with higher risk of new onset CKD. The long-term kidney safety of oral iron replacement should be tested in clinical trials.
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Affiliation(s)
- Prabin Shrestha
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shejuti Paul
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Satya Surbhi
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Connie M Rhee
- Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
- Long Beach VA Medical Center, Long Beach, California, USA
| | - Kamyar Kalantar-Zadeh
- Long Beach VA Medical Center, Long Beach, California, USA
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, Habor-UCLA Medical Center and the Lundquist Institute, Torrance, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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Paul S, Shrestha P, Sumida K, Thomas F, Surbhi S, Naser AM, Streja E, Rhee CM, Kalantar-Zadeh K, Kovesdy CP. Association of oral iron replacement therapy with kidney failure and mortality in CKD patients. Clin Kidney J 2023; 16:2082-2090. [PMID: 37915900 PMCID: PMC10616436 DOI: 10.1093/ckj/sfad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Indexed: 11/03/2023] Open
Abstract
Background Oral iron is the predominant route of iron replacement (IRT) but its benefits and safety are unclear in patients with chronic kidney disease (CKD). Methods We examined the association of oral IRT vs no IRT with end-stage kidney disease (ESKD) and mortality in a national cohort of US Veterans. We identified 17 413 incident new users of oral IRT with estimated glomerular filtration rates <60 mL/min/1.73 m2 and 32 530 controls who did not receive any IRT during 2004-18. We used propensity score-overlap weighting to account for differences in key baseline characteristics associated with the use of oral IRT. We examined associations using competing risk regression and Cox models. Results In the cohort of 49 943 patients, 1616 (3.2%) patients experienced ESKD and 28 711 (57%) patients died during a median follow-up of 1.9 years. Oral IRT was not associated with ESKD [subhazard ratio (HR) (95% confidence interval, CI) 1.00 (0.84-1.19), P = .9] and was associated with higher risk of all-cause mortality [HR (95% CI) 1.06 (1.01-1.11), P = .01]. There was significant heterogeneity of treatment effect for mortality, with oral IRT associated with higher mortality in the subgroups of patients without congestive heart failure (CHF), anemia or iron deficiency. In patient with blood hemoglobin <10 g/dL oral IRT was associated with significantly lower mortality. Conclusion Oral IRT was associated with lower mortality only in patients with anemia. In patients without anemia, iron deficiency or CHF, the risk-benefit ratio of oral IRT should be further examined.
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Affiliation(s)
- Shejuti Paul
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Prabin Shrestha
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satya Surbhi
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Abu Mohd Naser
- Division of Epidemiology, Biostatistics, and Environmental Health, University of Memphis, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California-Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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Whittaker CF, Miklich MA, Patel RS, Fink JC. Medication Safety Principles and Practice in CKD. Clin J Am Soc Nephrol 2018; 13:1738-1746. [PMID: 29915131 PMCID: PMC6237057 DOI: 10.2215/cjn.00580118] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ensuring patient safety is a priority of medical care because iatrogenic injury has been a primary concern. Medications are an important source of medical errors, and kidney disease is a thoroughfare of factors threatening safe administration of medicines. Principal among these is reduced kidney function because almost half of all medications used are eliminated via the kidney. Additionally, kidney patients often suffer from multimorbidity, including diabetes, hypertension, and heart failure, with a range of prescribers who often do not coordinate treatments. Patients with kidney disease are also susceptible to further kidney injury and metabolic derangements from medications, which can worsen the disease. In this review, we will present the key issues and threats to safe medication use in kidney disease, with a focus on predialysis CKD, as the scope of medication safety in ESKD and transplantation are unique and deserve their own consideration. We discuss drugs that need to be avoided or dose modified, and review the complications of a range of medications routinely administered in CKD, as these also call for cautious use.
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Affiliation(s)
- Chanel F. Whittaker
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Margaret A. Miklich
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Roshni S. Patel
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Philadelphia, Pennsylvania; and
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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4
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Yagil Y, Fadem SZ, Kant KS, Bhatt U, Sika M, Lewis JB, Negoi D. Managing hyperphosphatemia in patients with chronic kidney disease on dialysis with ferric citrate: latest evidence and clinical usefulness. Ther Adv Chronic Dis 2015; 6:252-63. [PMID: 26336594 DOI: 10.1177/2040622315589934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Ferric citrate is a novel phosphate binder that allows the simultaneous treatment of hyperphosphatemia and iron deficiency in patients being treated for end-stage renal disease with hemodialysis (HD). Multiple clinical trials in HD patients have uniformly and consistently demonstrated the efficacy of the drug in controlling hyperphosphatemia with a good safety profile, leading the US Food and Drug Administration in 2014 to approve its use for that indication. A concurrent beneficial effect, while using ferric citrate as a phosphate binder, is its salutary effect in HD patients with iron deficiency being treated with an erythropoietin-stimulating agent (ESA) in restoring iron that becomes available for reversing chronic kidney disease (CKD)-related anemia. Ferric citrate has also been shown in several studies to diminish the need for intravenous iron treatment and to reduce the requirement for ESA. Ferric citrate is thus a preferred phosphate binder that helps resolve CKD-related mineral bone disease and iron-deficiency anemia.
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Affiliation(s)
- Yoram Yagil
- Department of Nephrology and Hypertension, Barzilai University Medical Center, 2 Hahistadrut St, Ashkelon 78278, Israel
| | - Stephen Z Fadem
- Division of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Kotagal S Kant
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, USA
| | - Udayan Bhatt
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mohammed Sika
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julia B Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dana Negoi
- Department of Nephrology and Hypertension, University of Vermont Medical Group, Burlington, VT, USA
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5
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Vikrant S, Parashar A. The safety and efficacy of high dose ferric carboxymaltose in patients with chronic kidney disease: A single center study. Indian J Nephrol 2015. [PMID: 26199472 PMCID: PMC4495475 DOI: 10.4103/0971-4065.144421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Ferric carboxymaltose (FCM) is a parenteral, dextran-free iron formulation designed to overcome the limitations of existing intravenous (IV) iron preparations. We investigated the safety and efficacy of high dose administration of FCM in our anemic chronic kidney disease (CKD) patients. It was a prospective observational study from June 2011 to August 2013. FCM was administered as IV infusion 1000 mg in 250 ml of normal saline over 15-30 min. Efficacy was evaluated by comparing the Hb and/or serum iron status at the first follow-up visit after the infusion with that at the baseline. A total of 500 infusions were administered to 450 patients. All patients had a successful administration of the FCM. None of the patients had any serious drug-related AE. AE of mild to moderate severity observed or reported after the infusion were: accelerated hypertension (0.2%), feeling abnormal (0.6%), headache and bodyaches (0.6% each), and infusion site reaction (0.8%). 261 patients had a follow up Hb, which showed an increase of 1.7 ± 1.5 g/dl after a period of 11 ± 7.2 weeks (P = 0.001); 188 (72%) patients had a rise in Hb of ≥1 g/dl. The increase in Hb was observed uniformly across all stages of CKD. Proportions of patients with an Hb of above 10 and 11 g/dl increased from 30.2% to 62.8% and 16.1% to 37.9%, respectively (P = 0.001). Iron status evaluation done in 44 patients after a follow up period of 15.1 ± 11.5 weeks showed increases in Hb of 1.6 ± 2.2 g/dl (P = 0.001), transferrin saturation of 9.1 ± 16.9% (P = 0.001), and ferritin of 406 ± 449 ng/ml (P = 0.001). We conclude high dose administration of FCM is safe and well-tolerated. It was effective in the treatment of iron deficiency in nondialysis and peritoneal dialysis CKD patients.
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Affiliation(s)
- S Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - A Parashar
- Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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Connor JR, Zhang X, Nixon AM, Webb B, Perno JR. Comparative evaluation of nephrotoxicity and management by macrophages of intravenous pharmaceutical iron formulations. PLoS One 2015; 10:e0125272. [PMID: 25973894 PMCID: PMC4431721 DOI: 10.1371/journal.pone.0125272] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 03/23/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is a significant clinical need for effective treatment of iron deficiency. A number of compounds that can be administered intravenously have been developed. This study examines how the compounds are handled by macrophages and their relative potential to provoke oxidative stress. METHODS Human kidney (HK-2) cells, rat peritoneal macrophages and renal cortical homogenates were exposed to pharmaceutical iron preparations. Analyses were performed for indices of oxidative stress and cell integrity. In addition, in macrophages, iron uptake and release and cytokine secretion was monitored. RESULTS HK-2 cell viability was decreased by iron isomaltoside and ferumoxytol and all compounds induced lipid peroxidation. In the renal cortical homogenates, lipid peroxidation occurred at lowest concentrations with ferric carboxymaltose, iron dextran, iron sucrose and sodium ferric gluconate. In the macrophages, iron sucrose caused loss of cell viability. Iron uptake was highest for ferumoxytol and iron isomaltoside and lowest for iron sucrose and sodium ferric gluconate. Iron was released as secretion of ferritin or as ferrous iron via ferroportin. The latter was blocked by hepcidin. Exposure to ferric carboxymaltose and iron dextran resulted in release of tumor necrosis factor α. CONCLUSIONS Exposure to iron compounds increased cell stress but was tissue and dose dependent. There was a clear difference in the handling of iron from the different compounds by macrophages that suggests in vivo responses may differ.
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Affiliation(s)
- James R. Connor
- Department of Neurosurgery, M.S. Hershey Penn State University College of Medicine, M.S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Xuesheng Zhang
- Department of Neurosurgery, M.S. Hershey Penn State University College of Medicine, M.S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Anne M. Nixon
- Department of Neurosurgery, M.S. Hershey Penn State University College of Medicine, M.S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Becky Webb
- Department of Neurosurgery, M.S. Hershey Penn State University College of Medicine, M.S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Joseph R. Perno
- Luitpold Pharmaceuticals, Inc., Norristown, Pennsylvania, United States of America
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7
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Gillespie IA, Macdougall IC, Richards S, Jones V, Marcelli D, Froissart M, Eckardt KU. Factors precipitating erythropoiesis-stimulating agent responsiveness in a European haemodialysis cohort: case-crossover study. Pharmacoepidemiol Drug Saf 2015; 24:414-26. [PMID: 25690434 PMCID: PMC5024014 DOI: 10.1002/pds.3755] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 12/01/2014] [Accepted: 12/18/2014] [Indexed: 01/05/2023]
Abstract
Purpose Hyporesponsiveness to erythropoiesis‐stimulating agents (ESAs) is clinically and economically important in the treatment of anaemia in chronic kidney disease (CKD) patients. Previous studies focused on baseline predictors of ESA hyporesponsiveness, rather than factors associated with the transition to this state. Reversibility of ESA hyporesponsiveness has also not been studied previously. Methods Case‐crossover methodology was applied to a cohort of 6645 European CKD patients undergoing haemodialysis and prescribed ESAs. Ninety‐day ESA exposure periods were defined, haemoglobin (Hb) response was calculated using the last 30 days of one period and the first 30 days of the next, and periods were classified based on a median ESA dose (80.8 IU/kg/week) and a 10 g/dL Hb threshold. Clinical, dialysis and laboratory data from patients' first hyporesponsive ‘case’ period was compared with the preceding responsive ‘control’ period using conditional logistic regression. A similar approach was applied to hyporesponsiveness reversal. Results Of the patients, 672 experienced hyporesponsiveness periods with preceding responsive periods; 711 reversed to normality from hyporesponsiveness periods. Transition to hyporesponsiveness was associated with hospitalization, vascular access changes or worsening inflammation, with these factors accounting for over two‐thirds of transitions. Findings were largely insensitive to alternative ESA doses and Hb thresholds. Continued hospitalization, catheter insertion and uncontrolled secondary hyperparathyroidism were associated with a lack of regain of responsiveness. Conclusions Transition to hyporesponsiveness is linked to the development of conditions such as hospitalization events, vascular access issues or episodes of systemic inflammation. However, a third of hyporesponsive episodes remain unexplained. © 2015 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.
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Affiliation(s)
- Iain A Gillespie
- Center for Observational Research (CfOR), Amgen Ltd, Uxbridge, UK
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Pereira CA, Roscani MG, Zanati SG, Matsubara BB. Anemia, heart failure and evidence-based clinical management. Arq Bras Cardiol 2013; 101:87-92. [PMID: 23917508 PMCID: PMC3998166 DOI: 10.5935/abc.20130126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/05/2012] [Indexed: 12/21/2022] Open
Abstract
Anemia is a prevalent comorbidity and marker of a poorer prognosis in patients with
heart failure (HF). Its clinical relevance, as well as its pathophysiology and the
clinical management of these patients are important subjects in the specialized
literature. In the present review, we describe the current concepts on the
pathophysiology of anemia in HF, its diagnostic criteria, and the recommendations for
iron supplementation. Also, we make a critical analysis of the major studies showing
evidences on the benefits of this supplementation. The four main components of anemia
are addressed: chronic disease, dilutional, "renal" and malabsorption. In patients
with HF, the diagnostic criteria are the same as those used in the general
population: serum ferritin levels lower than 30 mcg/L in patients without kidney
diseases and lower than 100 mcg/L or serum ferritin levels between 100-299 mcg/L with
transferring saturation lower than 20% in patients with chronic kidney diseases.
Finally, the therapeutic possibilities for anemia in this specific patient population
are discussed.
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9
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Ornt DB, Larive B, Rastogi A, Rashid M, Daugirdas JT, Hernandez A, Kurella Tamura M, Suri RS, Levin NW, Kliger AS. Impact of frequent hemodialysis on anemia management: results from the Frequent Hemodialysis Network (FHN) Trials. Nephrol Dial Transplant 2013; 28:1888-98. [PMID: 23358899 DOI: 10.1093/ndt/gfs593] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The extent to which anemia management is facilitated by more frequent hemodialysis (HD) is controversial. We hypothesized as a preselected outcome that patients receiving HD six times (6×) compared with three times (3×) per week would require lower doses of erythropoietin-stimulating agents (ESA) and/or achieve higher blood hemoglobin (Hb) concentrations. METHODS Subjects enrolled in the Frequent Hemodialysis Network (FHN) daily and nocturnal trials were studied. As the primary outcome for anemia, the dose of ESAs was recorded at 4-month intervals and the monthly dose of intravenous iron (IV Fe) was reported. Serum iron, transferrin saturation and ferritin were measured at baseline and then at 4-month intervals, whereas Hb concentration was measured monthly. RESULTS There was no significant treatment effect in the 6× versus 3× treatment groups on logESA dose or the ratio of log of ESA dose to Hb concentration in either trial. In the daily trial, Hb concentrations increased significantly in the 6× versus 3× group, at Month 12 compared with baseline (0.3 g/dL; 95% CI: 0.05-0.58, P<0.021), but both groups had Hb concentrations in the usual target range. In the daily trial, the weekly logESA dose and the logESA dose to Hb concentration ratio tended to decline more in the 6× versus 3× group. This trend was not observed in the nocturnal trial. IV Fe doses were significantly lower in the 6× compared with the 3× group by Month 12 in the nocturnal trial, but not different in the daily trial. CONCLUSIONS In the FHN Daily and Nocturnal Trials, more frequent HD did not have a significant or clinically important effect on anemia management.
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Affiliation(s)
- Daniel B Ornt
- College of Health Sciences and Technology, Rochester Institute of Technology, Rochester, NY, USA.
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Ghoti H, Rachmilewitz EA, Simon-Lopez R, Gaber R, Katzir Z, Konen E, Kushnir T, Girelli D, Campostrini N, Fibach E, Goitein O. Evidence for tissue iron overload in long-term hemodialysis patients and the impact of withdrawing parenteral iron. Eur J Haematol 2012; 89:87-93. [PMID: 22435497 DOI: 10.1111/j.1600-0609.2012.01783.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIMS Erythropoiesis in long-term hemodialyzed (LTH) patients is supported by erythropoietin (rHuEpo) and intravenous (IV) iron. This treatment may end up in iron overload (IO) in major organs. We studied such patients for the parameters of IO in the serum and in major organs. METHODS Patients were treated with rHuEpo (6-8 x 10(3) units × 1-3/wk) and IV 100 mg ferric saccharate. RESULTS Of 115 patients, 21 had serum ferritin (SF) > 1000 ng/mL. This group was further analyzed. Their SF and transferrin saturation (TSAT) were 2688 ± 1489 ng/mL and 54.2 ± 32.7%, respectively (vs. 125-360 ng/mL and 20-50% in normal controls). Serum hepcidin was 60.1 ± 29.5 nm (vs. 10.61 ± 6.44 nm in controls) (P < 0.001). Nineteen patients had increased malonyldialdehyde, a product of lipid peroxidation, indicating oxidative stress. T2* MRI disclosed in 19 of 21 patients moderate to severe IO in the liver and spleen, in three of eight patients in the pancreas, but in no patient in the heart. After stopping IV iron for a mean of 12 months, while continuing rHuEpo, the mean SF decreased in 11 patients to 1682 ng/mL and the mean TSAT decreased to 28%, whereas hemoglobin did not change indicating that tissue iron was utilized. CONCLUSION High SF correlates with IO in the liver and spleen, but not in the heart.
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Affiliation(s)
- Hussam Ghoti
- Department of Hematology, E Wolfson Medical Center, Holon, Israel
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11
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Moore RA, Gaskell H, Rose P, Allan J. Meta-analysis of efficacy and safety of intravenous ferric carboxymaltose (Ferinject) from clinical trial reports and published trial data. BMC BLOOD DISORDERS 2011; 11:4. [PMID: 21942989 PMCID: PMC3206450 DOI: 10.1186/1471-2326-11-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 09/24/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recommendations given for intravenous iron treatment are typically not supported by a high level of evidence. This meta-analysis addressed this by summarising the available date from clinical trials of ferric carboxymaltose using clinical trial reports and published reports. METHODS Clinical trial reports were supplemented by electronic literature searches comparing ferric carboxymaltose with active comparators or placebo. Various outcomes were sought for efficacy (attainment of normal haemoglobin (Hb), increase of Hb by a defined amount, for example), together with measures of harm, including serious adverse events and deaths. RESULTS Fourteen studies were identified with 2,348 randomised patients exposed to ferric carboxymaltose, 832 to oral iron, 762 to placebo, and 384 to intravenous iron sucrose. Additional data were available from cohort studies. Intravenous ferric carboxymaltose was given up to the calculated iron deficit (up to 1,000 mg in one week) for iron deficiency anaemia secondary to chronic kidney disease, blood loss in obstetric and gynaecological conditions, gastrointestinal disease, and other conditions like heart failure. The most common comparator was oral iron, and trials lasted 1 to 24 weeks. Intravenous ferric carboxymaltose improved mean Hb, serum ferritin, and transferrin saturation levels; the mean end-of-trial increase over oral iron was, for Hb 4.8 (95% confidence interval 3.3 to 6.3) g/L, for ferritin 163 (153 to 173) μg/L, and for transferrin saturation 5.3% (3.7 to 6.8%). Ferric carboxymaltose was significantly better than comparator in achievement of target Hb increase (number needed to treat (NNT) 6.8; 5.3 to 9.7) and target Hb NNT (5.9; 4.7 to 8.1). Serious adverse events and deaths were similar in incidence in ferric carboxymaltose and comparators; rates of constipation, diarrhoea, and nausea or vomiting were lower than with oral iron. CONCLUSIONS This review examined the available trials of intravenous ferric carboxymaltose using details from published papers and unpublished clinical trial reports. It increases the evidence available to support recommendations given for intravenous iron treatment, but there are limited trial data comparing different intravenous iron preparations.
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Affiliation(s)
- R Andrew Moore
- Pain Research, Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe Hospitals, The Churchill, Oxford, OX3 7LJ, UK.
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Martín-del-Campo F, Batis-Ruvalcaba C, González-Espinoza L, Rojas-Campos E, Angel JR, Ruiz N, González J, Pazarín L, Cueto-Manzano AM. Dietary micronutrient intake in peritoneal dialysis patients: relationship with nutrition and inflammation status. Perit Dial Int 2011; 32:183-91. [PMID: 21804135 DOI: 10.3747/pdi.2010.00245] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare dietary intake of micronutrients by peritoneal dialysis (PD) patients according to their nutrition and inflammatory statuses. DESIGN This cross-sectional study evaluated 73 patients using subjective global assessment, 24-hour dietary recall, and markers of inflammation [C-reactive protein (CRP), tumor necrosis factor α, and interleukin 6]. RESULTS Half the patients had an inadequate micronutrient intake. Compared with dietary reference intakes, malnourished patients had lower intakes of iron (11 mg) and of vitamins C (45 mg) and B6 (0.8 mg). Malnourished and well-nourished patients both had lower intakes of sodium (366 mg, 524 mg respectively), potassium (1555 mg, 1963 mg), zinc (5 mg, 7 mg), calcium (645 mg, 710 mg), magnesium (161 mg, 172 mg), niacin (8 mg, 9 mg), folic acid (0.14 mg, 0.19 mg), and vitamin A (365 μg, 404 μg). Markers of inflammation were higher in malnourished than in well-nourished subjects. Compared with patients in lower quartiles, patients in the highest CRP quartile had lower intakes (p < 0.05) of sodium (241 mg vs 404 mg), calcium (453 mg vs 702 mg), vitamin B2 (0.88 mg vs 1.20 mg), and particularly vitamin A (207 μg vs 522 μg). CONCLUSIONS Among PD patients, half had inadequate dietary intakes of iron, zinc, calcium and vitamins A, B6, C, niacin, and folic acid. Lower micronutrient intakes were associated with malnutrition and inflammation. Patients with inflammation had lower intakes of sodium, calcium, and vitamins A and B2. Micronutrient intake must be investigated in various populations so as to tailor adequate supplementation.
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Abstract
The kidneys are famously responsible for maintaining external balance of prevalent minerals, such as sodium, chloride, and potassium. The kidney's role in handling trace minerals is more obscure to most nephrologists. Similarly, the impact of kidney failure on trace mineral metabolism is difficult to anticipate. The associated dietary modifications and dialysis create the potential for trace mineral deficiencies and intoxications. Indeed, there are numerous reports of dialysis-associated mishaps causing mineral intoxication, notable for the challenge of assigning causation. Equally challenging has been the recognition of mineral deficiency syndromes, amid what is often a cacophony of multiple comorbidities that vie for the attention of clinicians who care for patients with chronic kidney disease. In this paper, I review a variety of minerals, some of which are required for maintenance of normal human physiology (the U.S. Food and Drug Administration's list of essential minerals), and some that have attracted attention in the care of dialysis patients. For each mineral, I will discuss its role in normal physiology and will review reported deficiency and toxicity states. I will point out the interesting inter-relationships between several of the elements. Finally, I will address the special concerns of aluminum and magnesium as they pertain to the dialysis population.
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Affiliation(s)
- Richard K Kasama
- Division of Nephrology, UMDNJ-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey 08103 , USA.
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Charytan C. Bundled-Rate Legislation for Medicare Reimbursement for Dialysis Services: Implications for Anemia Management with ESAs. Clin J Am Soc Nephrol 2010; 5:2355-62. [DOI: 10.2215/cjn.04820610] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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Silverberg DS, Iaina A, Schwartz D, Wexler D. Intravenous Iron in Heart Failure: Beyond Targeting Anemia. Curr Heart Fail Rep 2010; 8:14-21. [DOI: 10.1007/s11897-010-0034-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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