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Miljuš G, Penezić A, Pažitná L, Gligorijević N, Baralić M, Vilotić A, Šunderić M, Robajac D, Dobrijević Z, Katrlík J, Nedić O. Glycosylation and Characterization of Human Transferrin in an End-Stage Kidney Disease. Int J Mol Sci 2024; 25:4625. [PMID: 38731843 PMCID: PMC11083005 DOI: 10.3390/ijms25094625] [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: 03/04/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
Chronic kidney disease (CKD) is a global health concern affecting approximately one billion individuals worldwide. End-stage kidney disease (ESKD), the most severe form of CKD, is often accompanied by anemia. Peritoneal dialysis (PD), a common treatment for ESKD, utilizes the peritoneum for solute transfer but is associated with complications including protein loss, including transferrin (Tf) a key protein involved in iron transport. This study investigated Tf characteristics in ESKD patients compared to healthy individuals using lectin microarray, spectroscopic techniques and immunocytochemical analysis to assess Tf interaction with transferrin receptors (TfRs). ESKD patients exhibited altered Tf glycosylation patterns, evidenced by significant changes in lectin reactivity compared to healthy controls. However, structural analyses revealed no significant differences in the Tf secondary or tertiary structures between the two groups. A functional analysis demonstrated comparable Tf-TfR interaction in both PD and healthy samples. Despite significant alterations in Tf glycosylation, structural integrity and Tf-TfR interaction remained preserved in PD patients. These findings suggest that while glycosylation changes may influence iron metabolism, they do not impair Tf function. The study highlights the importance of a glucose-free dialysis solutions in managing anemia exacerbation in PD patients with poorly controlled anemia, potentially offering a targeted therapeutic approach to improve patient outcomes.
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Affiliation(s)
- Goran Miljuš
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Ana Penezić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Lucia Pažitná
- Institute of Chemistry, Slovak Academy of Sciences, 84538 Bratislava, Slovakia
| | - Nikola Gligorijević
- Institute of Chemistry, Technology and Metallurgy, Department of Chemistry, University of Belgrade, 11000 Belgrade, Serbia
| | - Marko Baralić
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Clinic of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Aleksandra Vilotić
- Institute for the Application of Nuclear Energy (INEP), Department for Biology of Reproduction, University of Belgrade, 11000 Belgrade, Serbia
| | - Miloš Šunderić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Dragana Robajac
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Zorana Dobrijević
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
| | - Jaroslav Katrlík
- Institute of Chemistry, Slovak Academy of Sciences, 84538 Bratislava, Slovakia
| | - Olgica Nedić
- Institute for the Application of Nuclear Energy (INEP), Department for Metabolism, University of Belgrade, 11000 Belgrade, Serbia
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Gutiérrez OM. Treatment of Iron Deficiency Anemia in CKD and End-Stage Kidney Disease. Kidney Int Rep 2021; 6:2261-2269. [PMID: 34514189 PMCID: PMC8418942 DOI: 10.1016/j.ekir.2021.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 01/27/2023] Open
Abstract
Iron deficiency is common in individuals with chronic kidney disease and plays a major role in the development of anemia. Oral and intravenous iron agents are both available to replete iron in patients with chronic kidney disease diagnosed with iron deficiency. The choice of which agent to use is most often dictated by goals of therapy, tolerability, convenience, and response to prior therapy. Diminished absorption of iron in the gastrointestinal tract and a high incidence of gastrointestinal adverse effects can reduce the efficacy of oral iron agents, necessitating the use of i.v. iron formulations to treat iron deficiency anemia, particularly in patients requiring kidney replacement therapy. Newer oral agents may help to overcome these limitations and help treat iron deficiency in those not requiring kidney replacement therapy. Recent studies have provided new evidence that more aggressive repletion of iron in patients with chronic kidney disease requiring kidney replacement therapy may provide benefits with respect to anemia management and hard clinical outcomes such as cardiovascular disease and survival.
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Affiliation(s)
- Orlando M. Gutiérrez
- Division of Nephrology, Department of Medicine and Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Li PKT, Choy ASM, Bavanandan S, Chen W, Foo M, Kanjanabuch T, Kim YL, Nakayama M, Yu X. Anemia Management in Peritoneal Dialysis: Perspectives From the Asia Pacific Region. Kidney Med 2021; 3:405-411. [PMID: 34136787 PMCID: PMC8178472 DOI: 10.1016/j.xkme.2021.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Anemia is an important complication in patients with chronic kidney disease. Peritoneal dialysis (PD) is one of the most common modalities of kidney replacement therapy for patients with end-stage kidney disease. PD is particularly prevalent in the Asian Pacific region. Among the different countries and regions, including mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, and Thailand, PD accounts for 2.8% to 74.6% of the dialysis population. In addition, 82% to 96% of the PD populations from these countries and regions are receiving erythropoiesis-stimulating agents (ESAs). Asian Pacific countries and regions follow the latest KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the initiation of treatment of anemia in PD patients. The types of ESAs commonly used include shorter-acting (epoetin alfa and beta) and longer-acting agents, including darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. The most commonly used ESAs in Mainland China, Malaysia, Singapore, and Thailand are the shorter-acting agents, whereas in Hong Kong, Japan, and South Korea, longer-acting ESAs are most common. Oral iron therapy is still the most commonly used iron supplement. The route and dosage of iron administration in PD patients requires more research studies. With the introduction of oral hypoxia-inducible factor prolyl hydroxylase inhibitors into clinical use, the landscape of treatment of anemia in the PD population in the Asia Pacific region may change in the coming years.
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Affiliation(s)
- Philip Kam Tao Li
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Agnes Shin Man Choy
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Sunita Bavanandan
- Department of Nephrology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, National Health Commission of China and Guangdong Province, Guangzhou, China
| | - Marjorie Foo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Talerngsak Kanjanabuch
- Center of Excellence in Kidney Metabolic Disorders and Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong-Lim Kim
- School of Medicine, Kyungpook National University, Daegu, South Korea
| | | | - Xueqing Yu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangzhou, China
- Guangdong Academy of Medical Sciences, Guangzhou, China
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Minutolo R, Berto P, Liberti ME, Peruzzu N, Borrelli S, Netti A, Garofalo C, Conte G, De Nicola L, Del Vecchio L, Locatelli F. Ferric Carboxymatose in Non-Hemodialysis CKD Patients: A Longitudinal Cohort Study. J Clin Med 2021; 10:jcm10061322. [PMID: 33806864 PMCID: PMC8005153 DOI: 10.3390/jcm10061322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 11/28/2022] Open
Abstract
No information is available on the efficacy of ferric carboxymaltose (FCM) in real-world CKD patients outside the hemodialysis setting. We prospectively followed 59 non-hemodialysis CKD patients with iron deficient anemia (IDA: hemoglobin <12.0/<13.5 g/dL in women/men and TSAT < 20% and/or ferritin < 100 ng/mL) who were intolerant or non-responders to oral iron. Patients received ferric carboxymaltose (FCM) (single dose of 500 mg) followed by additional doses if iron deficiency persisted. We evaluated efficacy of FCM in terms of increase of hemoglobin, ferritin, and TSAT levels. Direct and indirect costs of FCM were also analyzed in comparison with a hypothetical scenario where same amount of iron as ferric gluconate (FG) was administered intravenously. During the 24 weeks of study, 847 ± 428 mg of FCM per patient were administered. IDA improved after four weeks of FCM and remained stable thereafter. At week-24, mean change (95%CI) from baseline of hemoglobin, ferritin and TSAT were +1.16 g/dL (0.55–1.77), +104 ng/mL (40–168) and +9.5% (5.8–13.2), respectively. These changes were independent from ESA use and clinical setting (non-dialysis CKD, peritoneal dialysis and kidney transplant). Among ESA-treated patients (n = 24), ESA doses significantly decreased by 26% with treatment and stopped either temporarily or persistently in nine patients. FCM, compared to a FG-based scenario, was associated with a cost saving of 288 euros/patient/24 weeks. Saving was the same in ESA users/non-users. Therefore, in non-hemodialysis CKD patients, FCM effectively corrects IDA and allows remarkable cost savings in terms of societal, healthcare and patient perspective.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
- Correspondence: ; Tel./Fax: +39-081-2549409
| | | | - Maria Elena Liberti
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Nicola Peruzzu
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Silvio Borrelli
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Antonella Netti
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Carlo Garofalo
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Giuseppe Conte
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Luca De Nicola
- Division of Nephrology, University of Campania, Luigi Vanvitelli, 80138 Naples, Italy; (M.E.L.); (N.P.); (S.B.); (A.N.); (C.G.); (G.C.); (L.D.N.)
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy;
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The Impact of Iron Supplementation for Treating Anemia in Patients with Chronic Kidney Disease: Results from Pairwise and Network Meta-Analyses of Randomized Controlled Trials. Pharmaceuticals (Basel) 2020; 13:ph13050085. [PMID: 32365757 PMCID: PMC7281268 DOI: 10.3390/ph13050085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022] Open
Abstract
After relative erythropoietin deficiency, iron deficiency is the second most important contributing factor for anemia in chronic kidney disease (CKD) patients. Iron supplementation is a crucial part of the treatment of anemia in CKD patients, and intravenous (IV) iron supplementation is considered to be superior to per os (PO) iron supplementation. The differences between the available formulations are poorly characterized. This report presents results from pairwise and network meta-analyses carried out after a comprehensive search in sources of published and unpublished studies, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations (International prospective register of systematic reviews PROSPERO reference ID: CRD42020148155). Meta-analytic calculations were performed for the outcome of non-response to iron supplementation (i.e., hemoglobin (Hgb) increase of <0.5–1.0 g/dL, or initiation/intensification of erythropoiesis-stimulating agent (ESA) therapy, or increase/change of iron supplement, or requirements of blood transfusion). A total of 34 randomized controlled trials (RCT) were identified, providing numerical data for analyses covering 93.7% (n = 10.097) of the total study population. At the network level, iron supplementation seems to have a more protective effect against the outcome of non-response before the start of dialysis than once dialysis is initiated, and some preparations seem to be more potent (e.g., ferumoxytol, ferric carboxymaltose), compared to the rest of iron supplements assessed (surface under the cumulative ranking area (SUCRA) > 0.8). This study provides parameters for adequately following-up patients requiring iron supplementation, by presenting the most performing preparations, and, indirectly, by making it possible to identify good responders among all patients treated with these medicines.
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Mitsopoulos E, Lysitska A, Pateinakis P, Lamprou V, Intzevidou E, Minasidis I, Katsaounou C, Kougioumtzidou O, Anagnostou N, Lemonidis N, Papadopoulou D. Efficacy and safety of a low monthly dose of intravenous iron sucrose in peritoneal dialysis patients. Int Urol Nephrol 2020; 52:387-392. [PMID: 31894555 DOI: 10.1007/s11255-019-02362-4] [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] [Received: 06/27/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Scientific data regarding intravenous iron supplementation in peritoneal dialysis (PD) patients are scarce. In attempting to administer the minimum monthly IV iron dose that could improve erythropoiesis, we wanted to assess the safety and efficacy of monthly maintenance intravenous administration of 100 mg iron sucrose in PD patients. METHODS In a 9-month prospective study, all clinically stable PD patients received intravenously 200 mg of iron sucrose as a loading dose, followed by monthly doses of 100 mg for five consecutive months. Levels of hemoglobin (Hb), ferritin, transferrin saturation (TSAT), reticulocyte hemoglobin content (CHr) and C-reactive protein (CRP) were measured before each administration and 3 months after the last iron infusion. Also, doses of concurrent erythropoietin administration were recorded. RESULTS Eighteen patients were eligible for the study. Mean levels of Hb and ferritin increased significantly (from 10.0 to 10.9 mg/dL, p = 0.01 and from 143 to 260 ng/mL, p = 0.005), as well as the increase in TSAT levels approached borderline significance (from 26.2 to 33.1%, p = 0.07). During the 6 months of iron administration, the erythropoietin dose was reduced in five patients and discontinued in one. During the 3 months following the last iron infusion, three of them again raised the erythropoietin dose to previous levels. None of the patients experienced any side effects related to IV iron administration. CONCLUSIONS A monthly maintenance intravenous dose of 100 mg iron sucrose may be a practical, effective, and safe in the short term, treatment of anemia in PD patients resulting in improved hemoglobin levels, iron indices, and erythropoietin response.
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Affiliation(s)
- Efstathios Mitsopoulos
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece.
| | - Aikaterini Lysitska
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Panagiotis Pateinakis
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Vasileios Lamprou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Eleni Intzevidou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Ilias Minasidis
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Chrysa Katsaounou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Ourania Kougioumtzidou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Nikolaos Anagnostou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Nikolaos Lemonidis
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
| | - Dorothea Papadopoulou
- Department of Nephrology, General Hospital of Thessaloniki Papageorgiou, Periferiaki Odos Thessalonikis, 56403, Nea Efkarpia, Greece
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Portolés-Pérez J, Durá-Gúrpide B, Merino-Rivas JL, Martín-Rodriguez L, Hevia-Ojanguren C, Burguera-Vion V, Yuste-Lozano C, Sánchez-García L, Rodriguez-Palomares JR, Paraiso V. Effectiveness and safety of ferric carboxymaltose therapy in peritoneal dialysis patients: an observational study. Clin Kidney J 2019; 14:174-180. [PMID: 33564416 PMCID: PMC7857829 DOI: 10.1093/ckj/sfz153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Background The efficacy of intravenous (IV) ferric carboxymaltose (FCM) has been demonstrated in haemodialysis and non-dialysis studies, but evidence is lacking in patients undergoing peritoneal dialysis (PD). Methods This multicentre, retrospective study evaluated the effectiveness and safety of FCM in patients on PD over 12 months. We retrospectively reviewed the electronic medical records of PD patients who initiated FCM treatment between 2014 and 2017 across seven Spanish centres. Results Ninety-one patients were included in the safety population (mean ± SD age 57.7 ± 15.0 years) and 70 in the efficacy population (mean age 50.9 ± 14.5 years). No hypersensitivity reaction, FCM discontinuation or dose adjustment due to a serious adverse event (SAE) was registered in the safety population. The most common non-SAEs reported were headache (four events), mild hypotension (three events) and hypertension (two events), among others. In the efficacy population (n = 70), 68.6% of patients achieved ferritin levels of 200–800 ng/mL, 78.4% achieved transferrin saturation (TSAT) >20%, and 62.8% achieved TSAT >20% and ferritin >200 ng/mL after 12 months of FCM initiation (P < 0.01). Haemoglobin (Hb) levels were maintained at >11 g/dL with a lower dose of darbepoetin throughout the follow-up. The sub-analysis of patients naïve to IV iron and with absolute or relative iron deficiency (n = 51) showed that 76.5% reached ferritin >200 ng/mL, 80.4% TSAT >20% and Hb increased (1.2 g/dL) after 4 months of FCM treatment (P < 0.01). Conclusion In this multicentre, retrospective, real-world study conducted in the PD population, FCM was effective, safe and easy to administer during routine clinical visits.
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Affiliation(s)
- Jose Portolés-Pérez
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | - Beatriz Durá-Gúrpide
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | | | - Leyre Martín-Rodriguez
- Nephrology Department, University Hospital Puerta de Hierro, Madrid, Spain.,RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain
| | | | - Victor Burguera-Vion
- RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain.,Nephrology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Claudia Yuste-Lozano
- RedInRen ISCiii 016/009 Public Research Net, Madrid, Spain.,Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | | | | | - Vicente Paraiso
- Nephrology Department, University Hospital del Henares, Coslada, Madrid, Spain
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Perlman RL, Zhao J, Fuller DS, Bieber B, Li Y, Pisoni RL, Robinson BM, Johnson DW, Kawanishi H, Davies SJ, Schreiber MJ, Perl J. International Anemia Prevalence and Management in Peritoneal Dialysis Patients. Perit Dial Int 2019; 39:539-546. [PMID: 31582465 DOI: 10.3747/pdi.2018.00249] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Background:The optimal treatment for managing anemia in peritoneal dialysis (PD) patients and best clinical practices are not completely understood. We sought to characterize international variations in anemia measures and management among PD patients.Methods:The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) enrolled adult PD patients from 6 countries from 2014 to 2017. Hemoglobin (Hb), ferritin levels, and transferrin saturation (TSAT), as well as erythropoiesis stimulating agents (ESAs) and iron use were compared cross-sectionally at study enrollment in Australia and New Zealand (A/NZ), Canada, Japan, the United Kingdom (UK), and the United States (US).Results:Among 3,603 PD patients from 193 facilities, mean Hb ranged from 11.0 - 11.3 g/dL across countries. The majority of patients (range 53% - 59%) had Hb 10 - 11.9 g/dL, with 4% - 12% patients ≥ 13 g/dL and 16% - 23% < 10 g/dL. Use of ESAs was higher in Japan (94% of patients) than elsewhere (66% - 79% of patients). In the US, 63% of patients had a ferritin level > 500 ng/mL, compared with 5% - 38% in other countries. In the US and Japan, 87% - 89% of PD patients had TSAT ≥ 20%, compared with 73% - 76% in other countries. Intravenous (IV) iron use within 4 months of enrollment was higher in the US (55% of patients) than elsewhere (6% - 17% patients).Conclusions:In this largest international observational study of anemia and anemia management in patients receiving PD, comparable Hb levels across countries were observed but with notable differences in ESA and iron use. Peritoneal dialysis patients in the US have higher ferritin levels and higher IV iron use than other countries.
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Affiliation(s)
- Rachel L Perlman
- University of Michigan Health Center, Ann Arbor, MI, USA .,Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Yun Li
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - David W Johnson
- University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | | | | | | - Jeffrey Perl
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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10
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Salim SA, Cheungpasitporn W, Elmaraezy A, Jawafi O, Rahman M, Aeddula NR, Tirupathi R, Fülöp T. Infectious complications and mortality associated with the use of IV iron therapy: a systematic review and meta-analysis. Int Urol Nephrol 2019; 51:1855-1865. [PMID: 31485910 DOI: 10.1007/s11255-019-02273-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents. Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality. We performed this meta-analysis to evaluate the incidence of infectious complications, hospitalizations and mortality with use of parenteral iron. METHODS Medical electronic databases [PubMed, EMBASE, Scopus, Web of Science, and cochrane central register for controlled clinical trials (CENTRAL)] were queried for studies that investigated the association between intravenous iron administration and infection in hemodialysis patients. 24 studies (8 Randomized control trials (RCTs) and 16 observational studies) were considered for qualitative and quantitative analysis. RESULTS All-cause mortality Data from 6 RCTs show that high-dose IV iron conferred 17% less all-cause mortality compared to controls; however, this outcome was not statistically significant (OR = 0.83, CI [0.7, 1.01], p = 0.07). Nine observational studies were pooled under the random effects model due to significant heterogeneity (I2 = 83%, p < 0.001). The overall HR showed increased risk of all-cause mortality in the high-dose group but was statistically non-significant (HR = 1.1, CI [1, 1.22], p = 0.06). Infections Four RCTs with no heterogeneity among their data (I2 = 0%, p = 0.61). Under the fixed effect model, there was no difference in the infection rate between high-dose iron and control group (OR = 0.97, CI [0.82, 1.16], p = 0.77); eight observational studies with significant heterogeneity and utilizing random effects model. Summary HR showed increased yet non-significant risk of infection in the high-dose group (HR = 1.13, CI [0.99, 1.28], p = 0.07) Hospitalization 1 RCT and six observational studies provided data for the rate of all-cause hospitalization. There was marked heterogeneity among observational studies. RCT showed no significant difference between high-dose iron and controls in the rate of hospitalization (OR = 1.03, CI [0.87, 1.23], p = 0.71). Summary HR for observational data showed increased rate of hospitalization in the high-dose group; however, this effect was not statistically significant (HR = 1.11, CI [0.99, 1.24], p = 0.07). Cardiovascular events One RCT compared the rate of adverse cardiovascular events between high-dose and low-dose iron. No significant difference was observed between the two groups (22.3% vs 25.6%, p = 0.12). Six heterogeneous observational studies (I2 = 65%, p < 0.001) reported on the rate of cardiovascular events. No significant difference was observed between high-dose iron and controls (HR = 1.18, CI [0.89, 1.57], p = 0.24). CONCLUSION High-dose parenteral iron does not seem to be associated with higher risk of infection, all-cause mortality, increased hospitalization or increased cardiovascular events on analysis of RCTs. Observational studies show increased risk for all-cause mortality, infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity.
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Affiliation(s)
- Sohail Abdul Salim
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA.
| | - Wisit Cheungpasitporn
- Department of Internal Medicine, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216-4505, USA
| | | | - Omar Jawafi
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | - Md Rahman
- Computational and Data-Enabled Science, Jackson State University, Jackson, MS, USA
| | | | | | - Tibor Fülöp
- Division of Nephrology, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA.,Raph H. Johnson VA Medical Center, Charleston, SC, USA
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11
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Henriksson HB, Papadimitriou N, Hingert D, Baranto A, Lindahl A, Brisby H. The Traceability of Mesenchymal Stromal Cells After Injection Into Degenerated Discs in Patients with Low Back Pain. Stem Cells Dev 2019; 28:1203-1211. [PMID: 31237488 DOI: 10.1089/scd.2019.0074] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Low back pain is a major health issue and one main cause to this condition is believed to be intervertebral disc (IVD) degeneration. Stem cell therapy for degenerated discs using mesenchymal stromal cells (MSCs) has been suggested. The aim of the study was to investigate the presence and distribution pattern of autologous MSCs transplanted into degenerated IVDs in patients and explanted posttransplantation. IVD tissues from four patients (41, 45, 47, and 47 years of age) participating in a clinical feasibility study on MSC transplantation to degenerative discs were investigated. Three patients decided to undergo fusion surgery at time points 8 months and one patient at 28 months posttransplantation. Pretransplantation, MSCs from bone marrow aspirate were isolated by centrifugation in FICOLL® test tubes and cultured (passage 1). Before transplantation, MSCs were labeled with 1 mg/mL iron sucrose (Venofer®) and 1 × 106 MSCs were transplanted into degenerated IVDs. At the time point of surgery, IVD tissues were collected. IVD tissue samples were fixated, embedded in paraffin, and sections prepared. IVD samples were stained with Prussian Blue, by which iron deposits are visualized and examined (light microscopy). Immunohistochemistry (IHC), including SOX9 (sex determining region Y box 9), Coll2A1 (collagen 2A1), and cell viability (TUNEL) were performed. Cells positive for iron deposits were observed in IVD tissues (3/4 patients). The cells/iron deposits were observed in clusters and/or as solitary cells in regions in IVD tissue samples [regions of interest (ROIs)]. By IHC, SOX9- and Coll2A1-positive cells were detected in the same regions as the detected cells/iron deposits. A few nonviable cells were detected by TUNEL assay in ROIs. Results demonstrated that MSCs, labeled with iron sucrose, transplanted into degenerated IVDs were detectable 8 months posttransplantation. The detected cellular activity indicates that MSCs have differentiated into chondrocyte-like cells and that the injected MSCs and/or their progeny have survived since the cells were found in large cluster and as solitary cells which were distributed at different parts of the IVD.
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Affiliation(s)
- Helena Barreto Henriksson
- Department of Orthopedics, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska Hospital, Gothenburg, Sweden.,Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nikolaos Papadimitriou
- Department of Orthopedics, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daphne Hingert
- Department of Orthopedics, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Adad Baranto
- Department of Orthopedics, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Lindahl
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Brisby
- Department of Orthopedics, Institute for Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
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12
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Kshirsagar AV, Li X. Long-Term Risks of Intravenous Iron in End-Stage Renal Disease Patients. Adv Chronic Kidney Dis 2019; 26:292-297. [PMID: 31477259 DOI: 10.1053/j.ackd.2019.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023]
Abstract
Patients with end-stage renal disease on dialysis commonly receive intravenous iron to treat anemia along with erythropoiesis-stimulating agents. While studies of intravenous iron have demonstrated efficacy in raising hemoglobin, the quantity of administered intravenous iron has raised concerns about iron overload leading to long-term toxicities. The goal of this review is to understand recent trends in intravenous iron use, potential mechanisms of iron toxicity, and to evaluate the available evidence in the literature for potential long-term cardiovascular and infectious complications. We include findings from the recently published landmark clinical trial of intravenous iron for patients receiving hemodialysis to contextualize treatment recommendations.
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13
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Cunha GJL, Rocha BML, Menezes Falcão L. Iron deficiency in chronic and acute heart failure: A contemporary review on intertwined conditions. Eur J Intern Med 2018; 52:1-7. [PMID: 29680173 DOI: 10.1016/j.ejim.2018.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/13/2022]
Abstract
Iron Deficiency (ID) is increasingly recognized as a prevalent comorbid condition in Heart Failure (HF). Despite this, the pathophysiological mechanisms for progressive ID in either chronic or acute HF are still poorly understood. Beyond the traditional factors for iron deficit in the general population, we ought to review the specificities of such paucity in the HF patient, particularly focusing on the interplay between heightened inflammation, overactivity of the sympathetic nervous system and the so-called cardio-renal-anaemia-ID syndrome. Currently, ID constitutes not only an independent prognostic marker but also a novel safe therapeutic target. Particularly, in selected stable HF patients with reduced left ventricular ejection fraction, intravenous (IV) iron improves symptomatic burden and reduces hospitalizations due to worsening HF. On this topic, the main trials of IV iron with either iron sucrose (Toblli et al., FERRIC-HF and IRON-HF) or ferric carboxymaltose (FAIR-HF, CONFIRM-HF and EFFECT-HF) will be summarized and discussed. Finally, we debate the gaps in knowledge of ID in special populations, namely the unreliability of routine plasmatic surrogate markers to assess iron status in acute and advanced HF, the challenging patient with both HF and Chronic Kidney Disease, as well as efficacy and safety concerns in these settings and the potential role of iron correction in cardiac resynchronization therapy candidates.
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Affiliation(s)
| | | | - Luiz Menezes Falcão
- Department of Internal Medicine, Hospital Santa Maria, Lisbon, Portugal; Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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14
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Hougen I, Collister D, Bourrier M, Ferguson T, Hochheim L, Komenda P, Rigatto C, Tangri N. Safety of Intravenous Iron in Dialysis: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2018; 13:457-467. [PMID: 29463597 PMCID: PMC5967668 DOI: 10.2215/cjn.05390517] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/22/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The safety of intravenous iron dosing in dialysis is uncertain. Higher-dose intravenous iron may be associated with a higher risk of infections, cardiovascular events, hospitalizations, and mortality. This systematic review aimed to determine the safety of higher-dose versus lower-dose intravenous iron, oral iron, or no iron supplementation in adult patients treated with dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched Medline, EMBASE, Cochrane library, and CINAHL from inception to January 6, 2017 for randomized, controlled trials and observational studies comparing higher-dose intravenous iron with lower-dose intravenous iron, oral iron, or no iron in patients treated with dialysis that had all-cause mortality, infection, cardiovascular events, or hospitalizations as outcomes. RESULTS Of the 2231 eligible studies, seven randomized, controlled trials and 15 observational studies met inclusion criteria. The randomized, controlled trials showed no association between higher-dose intravenous iron (>400 mg/mo for most studies) and mortality (six studies; n=970; pooled relative risk, 0.93; 95% confidence interval, 0.47 to 1.84; follow-up ranging from 35 days to 26 months) or infection (four studies; n=743; relative risk, 1.02; 95% confidence interval, 0.74 to 1.41). The observational studies showed no association between higher-dose intravenous iron (>200 mg/mo for most studies) and mortality (eight studies; n=241,408; hazard ratio, 1.09; 95% confidence interval, 0.98 to 1.21; follow-up ranging from 3 to 24 months), infection (eight studies; n=135,532; pooled hazard ratio, 1.13; 95% confidence interval, 0.99 to 1.28), cardiovascular events (seven studies; n=135,675; hazard ratio, 1.18; 95% confidence interval, 0.90 to 1.56), or hospitalizations (five studies; n=134,324; hazard ratio, 1.08; 95% confidence interval, 0.97 to 1.19). CONCLUSIONS Higher-dose intravenous iron does not seem to be associated with higher risk of mortality, infection, cardiovascular events, or hospitalizations in adult patients on dialysis. Strength of this finding is limited by small numbers of participants and events in the randomized, controlled trials and statistical heterogeneity in observational studies.
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Affiliation(s)
- Ingrid Hougen
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - David Collister
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mathieu Bourrier
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - Thomas Ferguson
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura Hochheim
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
| | - Paul Komenda
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; and
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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15
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Di Francesco T, Philipp E, Borchard G. Iron sucrose: assessing the similarity between the originator drug and its intended copies. Ann N Y Acad Sci 2017; 1407:63-74. [PMID: 29168243 DOI: 10.1111/nyas.13517] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/01/2017] [Accepted: 09/12/2017] [Indexed: 01/19/2023]
Abstract
Iron sucrose (IS) is a complex nanocolloidal intravenous suspension used in the treatment of iron-deficiency anemia. Follow-on IS products (iron sucrose similars (ISSs)) have obtained marketing authorization by the generic pathway, implying that identical copies of IS may be manufactured. However, recent prospective and retrospective clinical studies showed discrepancies in clinical outcomes, which might be related to differences in physicochemical properties. The aim of this work is to measure and compare the physicochemical properties of IS and three ISSs available in the market using innovative analytical procedures. The comprehensive elucidation of size, size distribution, morphology, and stability of these complex drugs revealed very significant differences between the products. This study serves to provide the basis to define critical quality attributes that may be linked to differences in clinical outcome and thus may contribute to an adequate regulatory approach for IS and its follow-on products.
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Affiliation(s)
- Tiziana Di Francesco
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Erik Philipp
- Vifor (International) AG, St. Gallen, Switzerland
| | - Gerrit Borchard
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
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16
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Macdougall IC. Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions. Clin Kidney J 2017; 10:i16-i24. [PMID: 29225819 PMCID: PMC5716151 DOI: 10.1093/ckj/sfx043] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 12/18/2022] Open
Abstract
Current recommendations for the use of intravenous iron therapy in the management of anaemia in patients with chronic kidney disease (CKD) are based on limited clinical evidence. Since the publication of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anaemia in Chronic Kidney Disease in 2012, a number of randomized clinical trials [notably, the Ferinject Assessment in Patients with Iron Deficiency Anaemia (FIND-CKD) and Randomized Trial to Evaluate IV and Oral Iron in Chronic Kidney Disease (REVOKE) trials] and observational studies have been completed, and a further large clinical trial—Proactive IV Iron Therapy in Dialysis Patients (PIVOTAL)—is currently underway. In this article, the implications of the findings from these recent studies are discussed and the critical evidence gaps that remain to be addressed are highlighted.
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17
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2015 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0114-y] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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18
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[Use of intravenous iron supplementation in chronic kidney disease: Interests, limits, and recommendations for a better practice]. Nephrol Ther 2015; 11:531-42. [PMID: 26498106 DOI: 10.1016/j.nephro.2015.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/19/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022]
Abstract
Iron deficiency is an important clinical concern in chronic kidney disease (CKD), giving rise to iron-deficiency anaemia, and various impaired cellular functions. Oral supplementation, in particular with ferrous salts, is associated with a high rate of gastro-intestinal side effects and is poorly absorbed, a problem that is avoided with intravenous (IV) irons. Recently, with the approval of the European Medicines Agency's Committee for Medicinal Products for Human Use, the French Agence nationale de sécurité du médicament et des produits de santé (ANSM) took adequate measures to minimize the risk of allergic reactions, by correction on the summary of intravenous iron products characteristics. All IV iron products should be prescribed, administered and injected, inside public or private hospitals exclusively, and a clinical follow-up after the infusion for at least 30 minutes is mandatory. The most stable intravenous iron complexes (low molecular weight iron dextran, ferric carboxymaltose, and iron isomaltoside 1000 [under agreement]) can be given in higher single doses and more rapidly than less recent preparations such as iron sucrose (originator or similars). Test doses are advisable for conventional low molecular weight iron dextrans, but are no more mandatory. Iron supplementation is recommended for all CKD patients with iron-deficiency anaemia and those who receive erythropoiesis-stimulating agents, whether or not they require dialysis. Intravenous iron is the preferred route of administration in haemodialysis patients, with randomized trials showing a significantly greater increase in haemoglobin levels for intravenous versus oral iron and a low rate of treatment-related adverse events during these trials. According ANSM, physicians should apply the product's label recommendations especially the posology. In the non-dialysis CKD population, the erythropoietic response is also significantly higher using intravenous versus oral iron, and tolerability is at least as good. Moreover in some non-dialysis patients, intravenous iron supplementation might avoid or at least delay the need for erythropoiesis-stimulating agents. Following the new ANSM's recommendations, we now have the ability to achieve iron stores replenishment correctly and conveniently in dialysis dependent and non-dialysis dependent CKD patients without compromising safety using the various pharmaceutical forms of iron products especially intravenous compounds.
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19
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Papadimitriou N, Li S, Barreto Henriksson H. Iron Sucrose-Labeled Human Mesenchymal Stem Cells: In Vitro Multilineage Capability and In Vivo Traceability in a Lapine Xenotransplantation Model. Stem Cells Dev 2015; 24:2403-12. [DOI: 10.1089/scd.2015.0140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nikolaos Papadimitriou
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susann Li
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
| | - Helena Barreto Henriksson
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
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20
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Avni T, Bieber A, Grossman A, Green H, Leibovici L, Gafter-Gvili A. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc 2015; 90:12-23. [PMID: 25572192 DOI: 10.1016/j.mayocp.2014.10.007] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/23/2014] [Accepted: 10/06/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To amass all available evidence regarding the safety of intravenous (IV) iron preparations to provide a true balance of efficacy and safety. METHODS Systematic review and meta-analysis of all randomized clinical trials comparing IV iron to another comparator. All electronic databases until January 1, 2014, were reviewed. Primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included all-cause mortality and other adverse events (AEs). Subgroup analysis was performed on the basis of type of IV iron, comparator, treated condition, and system involved. RESULTS A total of 103 trials published between 1965 through 2013 were included. A total of 10,390 patients were treated with IV iron compared with 4044 patients treated with oral iron, 1329 with no iron, 3335 with placebo, and 155 with intramuscular iron. There was no increased risk of SAEs with IV iron (relative risk [RR], 1.04; 95% CI, 0.93-1.17; I(2)=9%). Subgroup analysis revealed a decreased rate of SAEs when IV iron was used to treat heart failure (RR, 0.45; 95% CI, 0.29-0.70; I(2)=0%). Severe infusion reactions were more common with IV iron (RR, 2.47; 95% CI, 1.43-4.28; I(2)=0%). There was no increased risk of infections with IV iron. Gastrointestinal AEs were reduced with IV iron. CONCLUSION Intravenous iron therapy is not associated with an increased risk of SAEs or infections. Infusion reactions are more pronounced with IV iron.
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Affiliation(s)
- Tomer Avni
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Amir Bieber
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Grossman
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hefziba Green
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leonard Leibovici
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Gafter-Gvili
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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21
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Papadimitriou N, Thorfve A, Brantsing C, Junevik K, Baranto A, Barreto Henriksson H. Cell Viability and Chondrogenic Differentiation Capability of Human Mesenchymal Stem Cells After Iron Labeling with Iron Sucrose. Stem Cells Dev 2014; 23:2568-80. [DOI: 10.1089/scd.2014.0153] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nikolaos Papadimitriou
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Thorfve
- Department for Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University of Gothenburg, Gothenburg, Sweden
| | - Camilla Brantsing
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Junevik
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Adad Baranto
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helena Barreto Henriksson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
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Beguin Y, Jaspers A. Iron sucrose - characteristics, efficacy and regulatory aspects of an established treatment of iron deficiency and iron-deficiency anemia in a broad range of therapeutic areas. Expert Opin Pharmacother 2014; 15:2087-103. [PMID: 25186219 DOI: 10.1517/14656566.2014.953928] [Citation(s) in RCA: 18] [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
INTRODUCTION Iron is a key element in the transport and utilization of oxygen and a variety of metabolic pathways. Iron deficiency is a major cause of anemia and can be associated with fatigue, impaired physical function and reduced quality of life. Administration of oral or intravenous (i.v.) iron is the recommended treatment for iron-deficiency anemia (IDA) in different therapeutic areas. AREAS COVERED This article provides an overview of studies that evaluated i.v. iron sucrose for anemia and iron status management, either alone or in combination with erythropoiesis-stimulating agents, across various diseases and conditions. EXPERT OPINION Iron sucrose is an established, effective and well-tolerated treatment of IDA in patients with acute or chronic conditions such as chronic kidney disease, inflammatory bowel disease, pregnancy (second and third trimester), postpartum period, heavy menstrual bleeding and cancer who need rapid iron supply and in whom oral iron preparations are ineffective or not tolerated. Available data on patient blood management warrant further studies on preoperative iron treatment. First experience with iron sucrose follow-on products raises questions about their therapeutic equivalence without comparative clinical data in newly diagnosed patients or patients on existing chronic treatment.
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Affiliation(s)
- Yves Beguin
- University Hospital of Liège , Avenue de l'Hopital1, B-4000 Liège , Belgium +32 43 66 72 01 ; +32 43 66 88 55 ;
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Bailie GR, Larkina M, Goodkin DA, Li Y, Pisoni RL, Bieber B, Mason N, Tong L, Locatelli F, Marshall MR, Inaba M, Robinson BM. Variation in intravenous iron use internationally and over time: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2014; 28:2570-9. [PMID: 24078642 DOI: 10.1093/ndt/gft062] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To examine patterns of intravenous (IV) iron use across 12 countries from 1999 to 2011. METHODS Trends in iron use are described among 32 192 hemodialysis (HD) patients in the Dialysis Outcomes and Practice Patterns Study. Adjusted associations of IV iron dose with serum ferritin and transferrin saturation (TSAT) values were also studied. RESULTS IV iron was administered to 50% of patients over 4 months in 1999, increasing to 71% during 2009-11, with increasing use in most countries. Among patients receiving IV iron, the mean monthly dose increased from 232 ± 167 to 281 ± 211 mg. Most countries used 3 to 4 doses/month, but Canada used about 2 doses/month, Italy increased from 3 to almost 6 doses/month and Germany used 5 to 6 doses/month. The USA and most European countries predominantly used iron sucrose and sodium ferric gluconate. A significant use of iron dextran was limited to Canada and France; iron polymaltose was used in Australia and New Zealand; and Japan used ferric oxide saccharate, chondroitin polysulfate iron complex and cideferron. Ferritin values rose in most countries: 22% of patients had ≥ 800 ng/mL in the recent years of study. TSAT levels increased to a lesser degree over time. Japan had much lower IV iron dosing and ferritin levels, but similar TSAT levels. In adjusted analyses, serum ferritin and TSAT levels increased signifcantly by 14 ng/mL and 0.16%, respectively, for every 100 mg/month higher mean monthly iron dose. CONCLUSIONS IV iron prescription patterns varied between countries and changed over time from 1999 to 2011. IV iron use and dose increased in most countries, with notable increases in ferritin but not TSAT levels. With rising cumulative IV iron doses, studies of the effects of changing IV iron dosing and other anemia management practices on clinical outcomes should be a high priority.
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Affiliation(s)
- George R Bailie
- Albany Nephrology Pharmacy Group (ANephRx), Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials. BMJ 2013; 347:f4822. [PMID: 23950195 PMCID: PMC3805480 DOI: 10.1136/bmj.f4822] [Citation(s) in RCA: 231] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of intravenous iron, focusing primarily on its effects on haemoglobin, requirement for transfusion, and risk of infection. DESIGN Systematic review and meta-analysis of randomised controlled trials investigating the safety and efficacy of intravenous iron therapy. DATA SOURCES Randomised controlled trials from Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to June 2013, with no language restrictions. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible trials were randomised controlled trials of intravenous iron compared with either no iron or oral iron. Crossover and observational studies were excluded. MAIN OUTCOME MEASURES Change in haemoglobin concentration and risk of allogeneic red blood cell transfusion (efficacy) and risk of infection (safety). RESULTS Of the 75 trials meeting the inclusion criteria, 72 studies including 10 605 patients provided quantitative outcome data for meta-analysis. Intravenous iron was associated with an increase in haemoglobin concentration (standardised mean difference 6.5 g/L, 95% confidence interval 5.1 g/L to 7.9 g/L) and a reduced risk of requirement for red blood cell transfusion (risk ratio 0.74, 95% confidence interval 0.62 to 0.88), especially when intravenous iron was used with erythroid stimulating agents (ESAs) or in patients with a lower baseline plasma ferritin concentration. There were no significant interactions between the efficacy of intravenous iron and type or dose administered. Intravenous iron was, however, associated with a significant increase in risk of infection (relative risk 1.33, 95% confidence interval 1.10 to 1.64) compared with oral or no iron supplementation. The results remained similar when only high quality trials were analysed. CONCLUSIONS Intravenous iron therapy is effective in increasing haemoglobin concentration and reducing the risk of allogeneic red blood cell transfusion and could have broad applicability to a range of acute care settings. This potential benefit is counterbalanced by a potential increased risk of infection.
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Affiliation(s)
- Edward Litton
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia 6000.
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Abstract
Iron deficiency anemia is the most common form of anemia worldwide, caused by poor iron intake, chronic blood loss, or impaired absorption. Patients with inflammatory bowel disease (IBD) are increasingly likely to have iron deficiency anemia, with an estimated prevalence of 36%–76%. Detection of iron deficiency is problematic as outward signs and symptoms are not always present. Iron deficiency can have a significant impact on a patient’s quality of life, necessitating prompt management and treatment. Effective treatment includes identifying and treating the underlying cause and initiating iron replacement therapy with either oral or intravenous iron. Numerous formulations for oral iron are available, with ferrous fumarate, sulfate, and gluconate being the most commonly prescribed. Available intravenous formulations include iron dextran, iron sucrose, ferric gluconate, and ferumoxytol. Low-molecular weight iron dextran and iron sucrose have been shown to be safe, efficacious, and effective in a host of gastrointestinal disorders. Ferumoxytol is the newest US Food and Drug Administration-approved intravenous iron therapy, indicated for iron deficiency anemia in adults with chronic kidney disease. Ferumoxytol is also being investigated in Phase 3 studies for the treatment of iron deficiency anemia in patients without chronic kidney disease, including subgroups with IBD. A review of the efficacy and safety of iron replacement in IBD, therapeutic considerations, and recommendations for the practicing gastroenterologist are presented.
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Affiliation(s)
- Neil D Goldberg
- Emeritus Chief of Gastroenterology, University of Maryland St. Joseph Medical Center, Towson, MD, USA
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Solak Y, Atalay H, Guney I, Turkmen K, Kaya E, Turk S. Comparison of Adverse-Event Profiles of Intravenous Low-Molecular-Weight Iron Dextran and Iron Sucrose in Peritoneal Dialysis Patients. Ren Fail 2011; 33:307-11. [DOI: 10.3109/0886022x.2011.560404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Littlewood TJ, Alikhan R. The use of intravenous iron in patients with cancer-related anaemia. Br J Haematol 2008; 141:751-6. [PMID: 18410455 DOI: 10.1111/j.1365-2141.2008.07118.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intravenous iron has become the standard of care in patients with renal failure receiving treatment with erythropoiesis stimulating agents (ESAs) to treat true and functional iron deficiency and to prevent its development in haemodialysis patients. In cancer-related anaemia, several recently published, randomised studies suggested that intravenous iron improved haemoglobin response rates in ESA-treated patients compared to those treated with oral iron or placebo. The data supporting the efficacy of intravenous iron instead of oral iron in this setting are increasingly persuasive but larger randomised trials are needed before definitive recommendations are made.
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Affiliation(s)
- T J Littlewood
- Department of Haematology, Oxford Radcliffe NHS Trust, Oxford, UK.
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Wish JB, Coyne DW. Use of erythropoiesis-stimulating agents in patients with anemia of chronic kidney disease: overcoming the pharmacological and pharmacoeconomic limitations of existing therapies. Mayo Clin Proc 2007; 82:1371-80. [PMID: 17976358 DOI: 10.4065/82.11.1371] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Stage 3 chronic kidney disease (CKD), which is characterized by a glomerular filtration rate of 30 to 60 mL/min/1.73 m2 (reference range, 90-200 mL/min/1.73m2 for a 20-year-old, with a decrease of 4 mL/min per decade), affects approximately 8 million people in the United States. Anemia is common in patients with stage 3 CKD and, if not corrected, contributes to a poor quality of life. Erythropoiesis-stimulating agents (ESAs), introduced almost 2 decades ago, have replaced transfusions as first-line therapy for anemia. This review summarizes the current understanding of the role of ESAs in the primary care of patients with anemia of CKD and discusses pharmacological and pharmacoeconomic issues raised by recent data. Relevant studies in the English language were identified by searching the MEDLINE database (1987-2006). Two ESAs are currently available in the United States, epoetin alfa and darbepoetin alfa. More frequent dosing with epoetin alfa is recommended by the labeled administration guidelines because it has a shorter half-life than darbepoetin alfa. Clinical experience also supports extended dosing intervals for both these ESAs. Use of ESAs in the management of anemia of CKD is associated with improved quality of life, increased survival, and decreased progression of renal failure. Some evidence suggests that ESAs have a cardioprotective effect. However, correction of anemia to hemoglobin levels greater than 12 g/dL (to convert to g/L, multiply by 10) appears to increase the risk of adverse cardiac outcomes and progression of kidney disease in some patients. The prescription of ESAs in the primary care setting requires an understanding of the accepted use of these agents, the associated pharmacoeconomic challenges, and the potential risks. This review considers the need to balance effective ESA dosing intervals against the potential risks of treatment.
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Affiliation(s)
- Jay B Wish
- Division of Nephrology, Case Western Reserve University, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106, USA.
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MONIEM KHALIDA, BHANDARI SUNIL. Bolus intraperitoneal iron versus intravenous iron in peritoneal dialysis patients: a prospective study. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00058.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Anemia is a common complication of chronic kidney disease. Although mechanisms involved in the pathogenesis of renal anemia include chronic inflammation, iron deficiency, and shortened half-life of erythrocytes, the primary cause is deficiency of erythropoietin (EPO). Serum EPO levels in patients with chronic kidney disease are usually within the normal range and thus fail to show an appropriate increase with decreasing hemoglobin levels, as found in nonrenal anemias. Studies elucidating the regulation of EPO expression led to the identification of the hypoxia inducible factor-hypoxia responsive element system. However, despite much progress in understanding the molecular mechanisms through which cells can sense oxygen availability and translate this information into altered gene expression, the reason why EPO production is inappropriately low in diseased kidneys remains incompletely understood. Both alterations in the function of EPO-producing cells and perturbations of the oxygen-sensing mechanism in the kidney may contribute. As with other anemias, the consequences of renal anemia are a moderate decrease in tissue oxygen tensions and counterregulatory mechanisms that maintain total oxygen consumption, including a persistent increase in cardiac output.
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Affiliation(s)
- Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo School of Medicine, Tokyo, Japan.
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Zager RA. Intravenous Iron Therapy in Peritoneal Dialysis Patients: Short-Term Efficacy and Long-Term Issues. Clin J Am Soc Nephrol 2006; 1:353-5. [PMID: 17699230 DOI: 10.2215/cjn.00740306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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