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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P. Identification of three mechanistic pathways for iron-deficient heart failure. Eur Heart J 2024; 45:2281-2293. [PMID: 38733250 DOI: 10.1093/eurheartj/ehae284] [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: 11/13/2023] [Revised: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Current understanding of iron-deficient heart failure is based on blood tests that are thought to reflect systemic iron stores, but the available evidence suggests greater complexity. The entry and egress of circulating iron is controlled by erythroblasts, which (in severe iron deficiency) will sacrifice erythropoiesis to supply iron to other organs, e.g. the heart. Marked hypoferraemia (typically with anaemia) can drive the depletion of cardiomyocyte iron, impairing contractile performance and explaining why a transferrin saturation < ≈15%-16% predicts the ability of intravenous iron to reduce the risk of major heart failure events in long-term trials (Type 1 iron-deficient heart failure). However, heart failure may be accompanied by intracellular iron depletion within skeletal muscle and cardiomyocytes, which is disproportionate to the findings of systemic iron biomarkers. Inflammation- and deconditioning-mediated skeletal muscle dysfunction-a primary cause of dyspnoea and exercise intolerance in patients with heart failure-is accompanied by intracellular skeletal myocyte iron depletion, which can be exacerbated by even mild hypoferraemia, explaining why symptoms and functional capacity improve following intravenous iron, regardless of baseline haemoglobin or changes in haemoglobin (Type 2 iron-deficient heart failure). Additionally, patients with advanced heart failure show myocardial iron depletion due to both diminished entry into and enhanced egress of iron from the myocardium; the changes in iron proteins in the cardiomyocytes of these patients are opposite to those expected from systemic iron deficiency. Nevertheless, iron supplementation can prevent ventricular remodelling and cardiomyopathy produced by experimental injury in the absence of systemic iron deficiency (Type 3 iron-deficient heart failure). These observations, taken collectively, support the possibility of three different mechanistic pathways for the development of iron-deficient heart failure: one that is driven through systemic iron depletion and impaired erythropoiesis and two that are characterized by disproportionate depletion of intracellular iron in skeletal and cardiac muscle. These mechanisms are not mutually exclusive, and all pathways may be operative at the same time or may occur sequentially in the same patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX 75226, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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2
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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P, Talha KM. Critical re-evaluation of the identification of iron deficiency states and effective iron repletion strategies in patients with chronic heart failure. Eur J Heart Fail 2024; 26:1298-1312. [PMID: 38727791 DOI: 10.1002/ejhf.3237] [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: 12/22/2023] [Revised: 03/17/2024] [Accepted: 03/30/2024] [Indexed: 06/28/2024] Open
Abstract
According to current guidelines, iron deficiency is defined by a serum ferritin level <100 ng/ml or a transferrin saturation (TSAT) <20% if the serum ferritin level is 100-299 μg/L. These criteria were developed to encourage the use of intravenous iron as an adjunct to erythropoiesis-stimulating agents in the treatment of renal anaemia. However, in patients with heart failure, these criteria are not supported by any pathophysiological or clinical evidence that they identify an absolute or functional iron deficiency state. A low baseline TSAT-but not serum ferritin level-appears to be a reliable indicator of the effect of intravenous iron to reduce major heart failure events. In randomized controlled trials, intravenous iron decreased the risk of cardiovascular death or total heart failure hospitalization in patients with a TSAT <20% (risk ratio 0.67 [0.49-0.92]) but not in patients with a TSAT ≥20% (risk ratio 0.99 [0.74-1.30]), with the magnitude of the risk reduction being proportional to the severity of hypoferraemia. Patients who were enrolled in clinical trials solely because they had a serum ferritin level <100 μg/L showed no significant benefit on heart failure outcomes, and it is noteworthy that serum ferritin levels of 20-300 μg/L lie entirely within the range of normal values for healthy adults. Current guidelines reflect the eligibility criteria of clinical trials, which inadvertently adopted unvalidated criteria to define iron deficiency. Reliance on these guidelines would lead to the treatment of many patients who are not iron deficient (serum ferritin level <100 μg/L but normal TSAT) and ignores the possibility of iron deficiency in patients with a low TSAT but with serum ferritin level of >300 μg/L. Importantly, analyses of benefit based on trial eligibility-driven guidelines substantially underestimate the magnitude of heart-failure-event risk reduction with intravenous iron in patients who are truly iron deficient. Based on all available data, we recommend a new mechanism-based and trial-tested approach that reflects the totality of evidence more faithfully than the historical process adopted by clinical investigators and by the guidelines. Until additional evidence is forthcoming, an iron deficiency state in patients with heart failure should be defined by a TSAT <20% (as long as the serum ferritin level is <400 μg/L), and furthermore, the use of a serum ferritin level <100 μg/L alone as a diagnostic criterion should be discarded.
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Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, and Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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3
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Cen Y, Wang P, Gao F, Jing M, Zhang Z, Yi P, Zhang G, Sun Y, Wang Y. Tetramethylpyrazine nitrone activates hypoxia-inducible factor and regulates iron homeostasis to improve renal anemia. Front Pharmacol 2022; 13:964234. [PMID: 36324690 PMCID: PMC9618660 DOI: 10.3389/fphar.2022.964234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/03/2022] [Indexed: 02/19/2024] Open
Abstract
Renal anemia is one of the most common complications of chronic kidney disease and diabetic kidney disease. Despite the progress made in recent years, there is still an urgent unmet clinical need for renal anemia treatment. In this research, we investigated the efficacy and mechanism of action of the novel tetramethylpyrazine nitrone (TBN). Animal models of anemia including the streptozotocin (STZ)-induced spontaneously hypertensive rats (SHR) and the cisplatin (CDDP)-induced C57BL/6J mice are established to study the TBN's effects on expression of hypoxia-inducible factor and erythropoietin. To explore the mechanism of TBN's therapeutic effect on renal anemia, cobalt chloride (CoCl2) is used in Hep3B/HepG2 cells to simulate a hypoxic environment. TBN is found to increase the expression of hypoxia-inducible factor HIF-1α and HIF-2α under hypoxic conditions and reverse the reduction of HIFs expression caused by saccharate ferric oxide (SFO). TBN also positively regulates the AMPK pathway. TBN stimulates nuclear transcription and translation of erythropoietin by enhancing the stability of HIF-1α expression. TBN has a significant regulatory effect on several major biomarkers of iron homeostasis, including ferritin, ferroportin (FPN), and divalent metal transporter-1 (DMT1). In conclusion, TBN regulates the AMPK/mTOR/4E-BP1/HIFs pathway, and activates the hypoxia-inducible factor and regulates iron homeostasis to improve renal anemia.
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Affiliation(s)
- Yun Cen
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University and Institute of New Drug Research, Jinan University College of Pharmacy, Guangzhou, China
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Peile Wang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Fangfang Gao
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Mei Jing
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Zaijun Zhang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Peng Yi
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Gaoxiao Zhang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Yewei Sun
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
| | - Yuqiang Wang
- Institute of New Drug Research and Guangzhou Key Laboratory of Innovative Chemical Drug Research in Cardio-cerebrovascular Diseases, Jinan University College of Pharmacy, Guangzhou, China
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Kondo S, Ferdousi F, Yamauchi K, Suidasari S, Yokozawa M, Harrabi MM, Tominaga KI, Isoda H. Comprehensive transcriptome analysis of erythroid differentiation potential of olive leaf in haematopoietic stem cells. J Cell Mol Med 2021; 25:7229-7243. [PMID: 34180123 PMCID: PMC8335692 DOI: 10.1111/jcmm.16752] [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: 12/22/2020] [Revised: 05/15/2021] [Accepted: 06/08/2021] [Indexed: 12/13/2022] Open
Abstract
Anaemia is one of the leading causes of disability in young adults and is associated with increased morbidity and mortality in elderly. With a global target to reduce the disease burden of anaemia, recent researches focus on novel compounds with the ability to induce erythropoiesis and regulate iron homeostasis. We aimed to explore the biological events and potential polypharmacological effects of water-extracted olive leaf (WOL) on human bone marrow-derived haematopoietic stem cells (hHSCs) using a comprehensive gene expression analysis. HPLC analysis identifies six bioactive polyphenols in the WOL. Treatment with WOL for 12 days regulated gene expressions related to erythroid differentiation, oxygen homeostasis, iron homeostasis, haem metabolism and Hb biosynthesis in hHSCs. Functional clustering analysis reveals several major functions of WOL such as ribosomal biogenesis and mitochondrial translation machinery, glycolytic process, ATP biosynthesis and immune response. Additionally, the colonies of both primitive and mature erythroid progenitors, CFU-E and BFU-E, were significantly increased in WOL-treated hHSCs. The expressions of erythroid markers, CD47, glycophorin A (GYPA), and transferrin receptor (TFRC) and adult Hb subunits-HBA and HBB were also confirmed in immunofluorescent staining and flow cytometer analysis in WOL-treated hHSCs. It is well known that induction of lineage-specific differentiation, as well as the maturation of early haematopoietic precursors into fully mature erythrocytes, involves multiple simultaneous biological events and complex signalling networks. In this regard, our genome-wide transcriptome profiling with microarray study on WOL-treated hHSCs provides general insights into the multitarget prophylactic and/or therapeutic potential of WOL in anaemia and other haematological disorders.
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Affiliation(s)
- Shinji Kondo
- R&D Center for Tailor-Made QOL, University of Tsukuba, Tsukuba, Japan
| | - Farhana Ferdousi
- Alliance for Research on the Mediterranean and North Africa (ARENA), University of Tsukuba, Tsukuba, Japan.,AIST-University of Tsukuba Open innovation laboratory for food and medicinal resource engineering (FoodMed-OIL), University of Tsukuba, Tsukuba, Japan.,Faculty of Life and Environmental Sciences, University of Tsukuba, Tsukuba, Japan
| | | | | | | | - Mohamed Moncef Harrabi
- Alliance for Research on the Mediterranean and North Africa (ARENA), University of Tsukuba, Tsukuba, Japan
| | - Ken-Ichi Tominaga
- AIST-University of Tsukuba Open innovation laboratory for food and medicinal resource engineering (FoodMed-OIL), University of Tsukuba, Tsukuba, Japan
| | - Hiroko Isoda
- R&D Center for Tailor-Made QOL, University of Tsukuba, Tsukuba, Japan.,Alliance for Research on the Mediterranean and North Africa (ARENA), University of Tsukuba, Tsukuba, Japan.,AIST-University of Tsukuba Open innovation laboratory for food and medicinal resource engineering (FoodMed-OIL), University of Tsukuba, Tsukuba, Japan.,Faculty of Life and Environmental Sciences, University of Tsukuba, Tsukuba, Japan
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5
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Garcia-Casal MN, Pasricha SR, Martinez RX, Lopez-Perez L, Peña-Rosas JP. Serum or plasma ferritin concentration as an index of iron deficiency and overload. Cochrane Database Syst Rev 2021; 5:CD011817. [PMID: 34028001 PMCID: PMC8142307 DOI: 10.1002/14651858.cd011817.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Reference standard indices of iron deficiency and iron overload are generally invasive, expensive, and can be unpleasant or occasionally risky. Ferritin is an iron storage protein and its concentration in the plasma or serum reflects iron stores; low ferritin indicates iron deficiency, while elevated ferritin reflects risk of iron overload. However, ferritin is also an acute-phase protein and its levels are elevated in inflammation and infection. The use of ferritin as a diagnostic test of iron deficiency and overload is a common clinical practice. OBJECTIVES To determine the diagnostic accuracy of ferritin concentrations (serum or plasma) for detecting iron deficiency and risk of iron overload in primary and secondary iron-loading syndromes. SEARCH METHODS We searched the following databases (10 June 2020): DARE (Cochrane Library) Issue 2 of 4 2015, HTA (Cochrane Library) Issue 4 of 4 2016, CENTRAL (Cochrane Library) Issue 6 of 12 2020, MEDLINE (OVID) 1946 to 9 June 2020, Embase (OVID) 1947 to week 23 2020, CINAHL (Ebsco) 1982 to June 2020, Web of Science (ISI) SCI, SSCI, CPCI-exp & CPCI-SSH to June 2020, POPLINE 16/8/18, Open Grey (10/6/20), TRoPHI (10/6/20), Bibliomap (10/6/20), IBECS (10/6/20), SCIELO (10/6/20), Global Index Medicus (10/6/20) AIM, IMSEAR, WPRIM, IMEMR, LILACS (10/6/20), PAHO (10/6/20), WHOLIS 10/6/20, IndMED (16/8/18) and Native Health Research Database (10/6/20). We also searched two trials registers and contacted relevant organisations for unpublished studies. SELECTION CRITERIA We included all study designs seeking to evaluate serum or plasma ferritin concentrations measured by any current or previously available quantitative assay as an index of iron status in individuals of any age, sex, clinical and physiological status from any country. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. We designed the data extraction form to record results for ferritin concentration as the index test, and bone marrow iron content for iron deficiency and liver iron content for iron overload as the reference standards. Two other authors further extracted and validated the number of true positive, true negative, false positive, false negative cases, and extracted or derived the sensitivity, specificity, positive and negative predictive values for each threshold presented for iron deficiency and iron overload in included studies. We assessed risk of bias and applicability using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. We used GRADE assessment to enable the quality of evidence and hence strength of evidence for our conclusions. MAIN RESULTS Our search was conducted initially in 2014 and updated in 2017, 2018 and 2020 (10 June). We identified 21,217 records and screened 14,244 records after duplicates were removed. We assessed 316 records in full text. We excluded 190 studies (193 records) with reasons and included 108 studies (111 records) in the qualitative and quantitative analysis. There were 11 studies (12 records) that we screened from the last search update and appeared eligible for a future analysis. We decided to enter these as awaiting classification. We stratified the analysis first by participant clinical status: apparently healthy and non-healthy populations. We then stratified by age and pregnancy status as: infants and children, adolescents, pregnant women, and adults. Iron deficiency We included 72 studies (75 records) involving 6059 participants. Apparently healthy populations Five studies screened for iron deficiency in people without apparent illness. In the general adult population, three studies reported sensitivities of 63% to 100% at the optimum cutoff for ferritin, with corresponding specificities of 92% to 98%, but the ferritin cutoffs varied between studies. One study in healthy children reported a sensitivity of 74% and a specificity of 77%. One study in pregnant women reported a sensitivity of 88% and a specificity of 100%. Overall confidence in these estimates was very low because of potential bias, indirectness, and sparse and heterogenous evidence. No studies screened for iron overload in apparently healthy people. People presenting for medical care There were 63 studies among adults presenting for medical care (5042 participants). For a sample of 1000 subjects with a 35% prevalence of iron deficiency (of the included studies in this category) and supposing a 85% specificity, there would be 315 iron-deficient subjects correctly classified as having iron deficiency and 35 iron-deficient subjects incorrectly classified as not having iron deficiency, leading to a 90% sensitivity. Thresholds proposed by the authors of the included studies ranged between 12 to 200 µg/L. The estimated diagnostic odds ratio was 50. Among non-healthy adults using a fixed threshold of 30 μg/L (nine studies, 512 participants, low-certainty evidence), the pooled estimate for sensitivity was 79% with a 95% confidence interval of (58%, 91%) and specificity of 98%, with a 95% confidence interval of (91%, 100%). The estimated diagnostic odds ratio was 140, a relatively highly informative test. Iron overload We included 36 studies (36 records) involving 1927 participants. All studies concerned non-healthy populations. There were no studies targeting either infants, children, or pregnant women. Among all populations (one threshold for males and females; 36 studies, 1927 participants, very low-certainty evidence): for a sample of 1000 subjects with a 42% prevalence of iron overload (of the included studies in this category) and supposing a 65% specificity, there would be 332 iron-overloaded subjects correctly classified as having iron overload and 85 iron-overloaded subjects incorrectly classified as not having iron overload, leading to a 80% sensitivity. The estimated diagnostic odds ratio was 8. AUTHORS' CONCLUSIONS At a threshold of 30 micrograms/L, there is low-certainty evidence that blood ferritin concentration is reasonably sensitive and a very specific test for iron deficiency in people presenting for medical care. There is very low certainty that high concentrations of ferritin provide a sensitive test for iron overload in people where this condition is suspected. There is insufficient evidence to know whether ferritin concentration performs similarly when screening asymptomatic people for iron deficiency or overload.
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Affiliation(s)
| | - Sant-Rayn Pasricha
- Division: Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Australia
| | | | | | - Juan Pablo Peña-Rosas
- Department of Nutrition and Food Safety, World Health Organization, Geneva, Switzerland
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6
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Fertrin KY. Diagnosis and management of iron deficiency in chronic inflammatory conditions (CIC): is too little iron making your patient sick? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:478-486. [PMID: 33275757 PMCID: PMC7727593 DOI: 10.1182/hematology.2020000132] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
While iron deficiency remains the most common cause of anemia worldwide, low iron stores are associated with symptoms regardless of the presence of typical microcytic, hypochromic anemia and may be hard to recognize in patients with concurrent inflammation. Diagnosing and treating iron deficiency become more of a challenge because markers of iron status are influenced by low-grade inflammation present in common conditions, such as chronic kidney disease, cirrhosis, or heart failure. Here I present a pragmatic way of interpreting diagnostic lab tests to help clinicians recognize patients who are most likely to benefit from iron supplementation, choose between oral and parenteral administration, and make personalized decisions when patients do not fit usual guidelines.
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7
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Restrepo-Gallego M, Díaz LE, Rondó PHC. Classic and emergent indicators for the assessment of human iron status. Crit Rev Food Sci Nutr 2020; 61:2827-2840. [PMID: 32619106 DOI: 10.1080/10408398.2020.1787326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Iron deficiency is the leading cause of anemia, a significant global public health problem. Different methods exist for assessing iron nutritional status, including laboratory tests that focus on storage, transportation, and iron functional compartment parameters. Classical markers such as bone marrow, serum iron, ferritin, hemoglobin, erythrocyte parameters, transferrin, transferrin receptors, and zinc protoporphyrin are discussed in this review. Additional parameters calculated from these indicators, including transferrin saturation, ferritin index and Thomas plot, and some emergent parameters such as hepcidin, erythroferrone, and low hemoglobin density are also discussed. There is no a single indicator for assessing iron nutritional status. Therefore, the use of more than one indicator may be the best practice to obtain the correct diagnosis, also considering the influence of inflammation/infection on many of these indicators. The constant validation of the current parameters, the improvement of assessment methods, and the identification of new indicators will be the key to refine the assessment of iron nutritional status and the right choice of treatment for its improvement.
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Affiliation(s)
| | - Luis E Díaz
- Doctorate Program in Bioscience, La Sabana University, Chía, Colombia
| | - Patrícia H C Rondó
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
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8
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Associations of Common Variants in HFE and TMPRSS6 Genes with Hepcidin-25 and Iron Status Parameters in Patients with End-Stage Renal Disease. DISEASE MARKERS 2019; 2019:4864370. [PMID: 30984307 PMCID: PMC6431474 DOI: 10.1155/2019/4864370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 02/02/2023]
Abstract
Background Influence of TMPRSS6 A736V and HFE (C282Y and H63D) polymorphisms on serum hepcidin-25 levels and iron status parameters in end-stage renal disease (ESRD) patients stratified according to gender has not been previously investigated. In addition, we aimed to evaluate the diagnostic accuracy of the parameters to separate iron-deficiency anemia (IDA) from anemia of chronic disease. Materials and Methods Iron status parameters and genetic analysis were performed in 126 ESRD patients and in 31 IDA patients as the control group. Results ESRD patients had significantly higher ferritin and hepcidin-25 (<0.001) relative to IDA patients. Cut-off values with the best diagnostic accuracy were found for hepcidin ≥9.32 ng/mL, ferritin ≥48.2 μg/L, transferrin saturation ≥16.8%, and MCV ≥81 fL. Interaction between gender and HFE haplotypes for the hepcidin-25 and ferritin levels in ESRD patients (p = 0.005, partial eta squared = 0.09; p = 0.027, partial eta squared = 0.06, respectively) was found. Serum transferrin was influenced by the combined effect of gender and TMPRSS6 A736V polymorphism in ESRD patients (p = 0.002, partial eta squared = 0.07). Conclusion Our findings could contribute to the further investigation of mechanisms involved in the pathophysiology and important gender-related involvement of the TMPRSS6 and HFE polymorphisms on anemia in ESRD patients.
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9
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Vela D. Systemic and local hepcidin as emerging and important peptides in renal homeostasis and pathology. Biofactors 2019; 45:118-134. [PMID: 30461080 DOI: 10.1002/biof.1468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
Recent data suggest that the importance of hepcidin goes beyond its classical role in controlling systemic iron metabolism. Local hepcidins are emerging as important peptides for organ homeostasis in the brain, heart, blood vessels, and in cancer as well. Similarly, accumulating data indicate that hepcidin does seem to be an important factor in renal homeostasis. This review encompasses present knowledge concerning the role of hepcidin in renoprotection and its use as a biomarker of kidney diseases. Understanding the role of hepcidin in kidneys is important due to its relevance for kidney physiology and its potential therapeutic application in kidney pathologies. © 2018 BioFactors, 45(2):118-134, 2019.
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Affiliation(s)
- Driton Vela
- Department of Physiology, Faculty of Medicine, University of Prishtina, Prishtina, Kosova
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10
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Kwiatkowska K, Winiarska-Mieczan A, Kwiecień M. Effect of Application of Fe-Glycinate Chelate in Diet for Broiler Chickens in an Amount Covering 50 or 25% of the Requirement on Physical, Morphometric and Strength Parameters of Tibia Bones. Biol Trace Elem Res 2018; 184:483-490. [PMID: 29119517 PMCID: PMC6061183 DOI: 10.1007/s12011-017-1171-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 09/26/2017] [Indexed: 12/19/2022]
Abstract
The purpose of the work was to check whether the application of Fe-glycinate chelate in mixtures fed to poultry in an amount covering 50 or 25% of the requirement would decrease the physical, morphometric and strength parameters of tibia bones in male Ross-308 broiler chickens in comparison to groups receiving Fe in an amount covering 100% of the requirement in the form of glycinate chelate or sulphate. It was found that the results for chickens from groups receiving Fe chelate covering 50 or 25% of the requirement were generally not lower than in the sulphate group and were higher than in the group receiving Fe in the amount covering 100% of the requirement. The presented results indicate that the standard requirement for Fe (40 mg kg-1 feed) as recommended by producers of Ross chickens may be too high if glycinate chelate is the source of Fe. This can be connected with the higher bioavailability of Fe from organic compounds in comparison to inorganic compounds.
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Affiliation(s)
- Katarzyna Kwiatkowska
- Institute of Animal Nutrition and Bromatology, University of Life Sciences in Lublin, Akademicka 13, 20-950, Lublin, Poland
| | - Anna Winiarska-Mieczan
- Institute of Animal Nutrition and Bromatology, University of Life Sciences in Lublin, Akademicka 13, 20-950, Lublin, Poland
| | - Małgorzata Kwiecień
- Institute of Animal Nutrition and Bromatology, University of Life Sciences in Lublin, Akademicka 13, 20-950, Lublin, Poland.
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11
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Xiang D, Wang X, Liu P, Pan Y, Zhang Q, Chi X, Jing Y, Duan X, Wei Q, Wang J, Li M, Wang C. Increased NGAL level associated with iron store in chronic kidney disease with anemia. Clin Exp Med 2018; 18:563-568. [PMID: 29909502 DOI: 10.1007/s10238-018-0507-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/20/2018] [Indexed: 11/30/2022]
Abstract
An iron scarcity often occurs in chronic kidney disease (CKD). Neutrophil gelatinase-associated lipocalin (NGAL), a biomarker of acute kidney injury, is associated with iron metabolism. The present study determined the association between serum NGAL and iron status in chronic kidney disease with anemia. A total of 154 adult CKD patients were divided into anemia and without anemia groups. The anemia groups were further subdivided into two groups based on the presence or absence of iron deficiency, defined as a transferrin saturation (TSAT) < 20%. The NGAL was measured for all the 154 patients, and the possible relationships with iron status were analyzed. 27.7% patients with TSAT < 20% presented lower hemoglobin, serum iron, serum ferritin, and higher NGAL values than those without iron deficiency. NGAL was inversely correlated with hemoglobin, hematocrit, MCV, MCH, serum iron, and TSAT. NGAL adequately diagnosed the status of iron deficiency among CKD patients by ROC analysis. The optimal NGAL cutoff value able to identify iron deficiency was found to be > 244.8 ng/mL, with 73.01% sensitivity and 68.29% specificity. CKD patients with anemia presented altered NGAL values as this protein is involved in the maintenance of iron balance. Thus, NGAL might be proposed as a new tool for assessing the iron deficiency and in the management of iron therapy for CKD patients.
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Affiliation(s)
- Daijun Xiang
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Xiuying Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Peipei Liu
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Yuling Pan
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Xiuping Chi
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Ying Jing
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Xinxin Duan
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Qiaozhen Wei
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Jianan Wang
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China
| | - Mianyang Li
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China.
| | - Chengbin Wang
- Department of Clinical Laboratory, Chinese PLA General Hospital, Beijing, China.
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12
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Xu Y, Peng H, Ke B. α-klotho and anemia in patients with chronic kidney disease patients: A new perspective. Exp Ther Med 2017; 14:5691-5695. [PMID: 29250136 PMCID: PMC5729369 DOI: 10.3892/etm.2017.5287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 04/11/2017] [Indexed: 12/17/2022] Open
Abstract
Normocytic normochromic anemia is a common complication of chronic kidney disease (CKD) and is associated with numerous adverse consequences. Certain symptoms previously attributed to CKD are now known to be a consequence of anemia. Anemia contributes to an increased cardiac output, and the development of left ventricular hypertrophy, angina and congestive heart failure, leading to high morbidity and mortality in patients with CKD. The multifunctional α-klotho (KL) protein, which is predominantly expressed in the kidneys, is associated with the occurrence of anemia in patients with CKD. The present review presents current evidence on the potential role of α-KL in renal anemia. Low expression of α-KL appears to improve anemia in patients with CKD, and has been hypothesized to be a compensatory mechanism to attenuate the effects of anemia in patients with CKD. Further understanding of the role of α-KL in renal anemia may offer novel insights into the treatment of patients with CKD complicated with anemia.
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Affiliation(s)
- Yang Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Hao Peng
- Nanchang University School of Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Ben Ke
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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13
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Mc Causland FR, Claggett B, Pfeffer MA, Burdmann EA, Eckardt KU, Levey AS, McMurray JJV, Remuzzi G, Singh AK, Solomon SD, Toto RD, Parfrey P. Change in Hemoglobin Trajectory and Darbepoetin Dose Approaching End-Stage Renal Disease: Data from the Trial to Reduce Cardiovascular Events with Aranesp Therapy Trial. Am J Nephrol 2017; 46:488-497. [PMID: 29241199 DOI: 10.1159/000485326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/08/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The pathogenesis of chronic kidney disease associated anemia is multifactorial and includes decreased production of erythropoietin (EPO), iron deficiency, inflammation, and EPO resistance. To better understand the trajectory of these parameters, we described temporal trends in hemoglobin (Hb), ferritin, transferrin saturation, C-reactive protein (CRP), and darbepoetin dosing in the Trial to Reduce cardiovascular Events with Aranesp Therapy (TREAT). METHODS We performed a post hoc analysis of 4,038 participants in TREAT. Mixed effects linear regression models were used to determine the trajectory of parameters of interest prior to end-stage renal disease (ESRD). Likelihood ratio tests were used to determine the overall differences in biomarker values and differences in trajectories between those who did and did not develop ESRD. RESULTS Hb declined precipitously in the year prior to the development of ESRD (irrespective of treatment assignment), and was on average 1.15 g/dL (95% CI -1.26 to -1.04) lower in those who developed ESRD versus those who did not, at the time of ESRD/end of follow-up. Simultaneously, the mean darbepoetin dose and CRP concentration increased, while serum ferritin and transferrin saturations were >140 μg/L and 20%, respectively. CONCLUSIONS Our analyses provide descriptive insights regarding the temporal changes of Hb, darbepoetin dose, and related parameters as ESRD approaches in participants of TREAT. Hb declined as much as 1-2 years prior to the development of ESRD, without biochemical evidence of iron deficiency. The most precipitous decline occurred in the months immediately prior to ESRD, despite administration of escalating doses of darbepoetin and in parallel with an increase in CRP.
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Affiliation(s)
- Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Claggett
- Harvard Medical School, Boston, Massachusetts, USA
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marc A Pfeffer
- Harvard Medical School, Boston, Massachusetts, USA
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emmanuel A Burdmann
- Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Giuseppe Remuzzi
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Ajay K Singh
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D Solomon
- Harvard Medical School, Boston, Massachusetts, USA
- Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert D Toto
- Renal Division, University of Texas Southwestern, Dallas, Texas, USA
| | - Patrick Parfrey
- Health Sciences Centre, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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14
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Karlsson T. Evaluation of a competitive hepcidin ELISA assay in the differential diagnosis of iron deficiency anaemia with concurrent inflammation and anaemia of inflammation in elderly patients. JOURNAL OF INFLAMMATION-LONDON 2017; 14:21. [PMID: 28936123 PMCID: PMC5604302 DOI: 10.1186/s12950-017-0166-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/04/2017] [Indexed: 12/11/2022]
Abstract
In this study, a competitive hepcidin ELISA assay was evaluated for its ability to differentiate between iron deficiency anaemia with concurrent inflammation and anaemia of inflammation in elderly patients, using the absence of stainable bone marrow iron as the diagnostic criterion for iron deficiency. In addition, correlation coefficients for hepcidin versus C-reactive protein, ferritin and interleukin-6 were determined. The optimal cut-off for hepcidin was 21 μg/L, corresponding to sensitivity and specificity of 100% and 67%, respectively, for iron deficiency. For ferritin, a sensitivity and specificity of 91% and 83%, respectively, correspond to an optimal cut-off of 87 μg/L. Receiver operating characteristics curve analysis revealed that ELISA analysis of hepcidin is not superior to ferritin in the diagnosis of iron deficiency in elderly anaemic patients with concurrent inflammation. Hepcidin shows a strong positive correlation with ferritin, and also correlates positively with C-reactive protein in this patient population.
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Affiliation(s)
- Torbjörn Karlsson
- Department of Haematology, Uppsala University Hospital, 751 85 Uppsala, Sweden
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15
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Reichert CO, da Cunha J, Levy D, Maselli LMF, Bydlowski SP, Spada C. Hepcidin: Homeostasis and Diseases Related to Iron Metabolism. Acta Haematol 2017; 137:220-236. [PMID: 28514781 DOI: 10.1159/000471838] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/20/2017] [Indexed: 12/14/2022]
Abstract
Iron is an essential metal for cell survival that is regulated by the peptide hormone hepcidin. However, its influence on certain diseases is directly related to iron metabolism or secondary to underlying diseases. Genetic alterations influence the serum hepcidin concentration, which can lead to an iron overload in tissues, as observed in haemochromatosis, in which serum hepcidin or defective hepcidin synthesis is observed. Another genetic imbalance of iron is iron-refractory anaemia, in which serum concentrations of hepcidin are increased, precluding the flow and efflux of extra- and intracellular iron. During the pathogenesis of certain diseases, the resulting oxidative stress, as well as the increase in inflammatory cytokines, influences the transcription of the HAMP gene to generate a secondary anaemia due to the increase in the serum concentration of hepcidin. To date, there is no available drug to inhibit or enhance hepcidin transcription, mostly due to the cytotoxicity described in the in vitro models. The proposed therapeutic targets are still in the early stages of clinical trials. Some candidates are promising, such as heparin derivatives and minihepcidins. This review describes the main pathways of systemic and genetic regulation of hepcidin, as well as its influence on the disorders related to iron metabolism.
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Affiliation(s)
- Cadiele Oliana Reichert
- Clinical Analysis Department, Health Sciences Center, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
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16
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Del Vecchio L, Longhi S, Locatelli F. Safety concerns about intravenous iron therapy in patients with chronic kidney disease. Clin Kidney J 2016; 9:260-7. [PMID: 26985378 PMCID: PMC4792617 DOI: 10.1093/ckj/sfv142] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 11/20/2015] [Indexed: 01/12/2023] Open
Abstract
Anaemia in chronic kidney disease (CKD) is managed primarily with erythropoiesis-stimulating agents (ESAs) and iron therapy. Following concerns around ESA therapy, intravenous (IV) iron is being administered more and more worldwide. However, it is still unclear whether this approach is safe at very high doses or in the presence of very high ferritin levels. Some observational studies have shown a relationship between either high ferritin level or high iron dose and increased risk of death, cardiovascular events, hospitalization or infection. Others have not been able to confirm these findings. However, they suffer from indication biases. On the other hand, the majority of randomized clinical trials have only a very short follow-up (and thus drug exposure) and are inadequate to assess the mortality risk. None of them have tested the role of different iron doses on hard end points. With the lack of clear evidence coming from well-designed and large-scale studies, several data suggest that excessive iron therapy may be toxic in several aspects, ranging from iron overload to tissue damage from labile iron. A number of experimental and clinical data suggest that either excessive iron therapy or iron overload may be a possible culprit of atherogenesis. The process seems to be mediated by oxidative stress. Iron therapy should also be used cautiously in the presence of active infections, since iron is essential for bacterial growth. Recently, the European Medicines Agency officially raised concerns about rare hypersensitivity reactions following IV iron administration. The balance has been in favour of benefits. In several European countries, this has created a lot of confusion and somewhat slowed the run towards excessive use. Altogether, IV iron remains a mainstay of anaemia treatment in CKD patients. However, in our opinion, its excessive use should be avoided, especially in patients with high ferritin levels and when ESA agents are not contraindicated.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
| | - Selena Longhi
- Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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