Is there prognostic or predictive significance in those approximately 5% dialysis patients who experience repeat exaggerated responses to even a single administration of modest doses of intravenous iron? [much higher than expected and more prolonged elevations of TSAT (serum iron/TIBC) and ferritin]?
Sometimes, the labs remain elevated for months after a modest IV iron administration.
While these labs are not perfect, they are currently the most commonly used markers to aid prescribing of iron therapy in dialysis.
This observation presents challenges for the treating prescriber.
It would be nice to know what is the significance to help guide therapy.
I'm not familiar enough with the use of soluble ferric pyrophosphate (SFP) to know if SFP would be a better choice for treatment of these patients.
I do not have full access to the below referenced article. While the focus may be different from the question above, I wonder if the authors noticed any significance for the observations referenced above.
Nephrology (Carlton). 2016 Jan 29.
Characterisation of hepatic and cardiac iron deposition during standard treatment of anaemia in haemodialysis.
Holman R1, Olynyk JK1,2, Kulkarni H3, Ferrari P4,5.
Please refer following articles:
doi: 10.1177/2040620712440071
doi: 10.1016/j.bbagen.2010.03.011
thank you for the kind response. by chance, would you be able to post these articles? I do not have full access to them. best, paul
Do these patients actually had iron deficiency? Do you know this article?
Thank you kindly Dr. Gillain-Martin for the resource. It is an excellent read.
I am uncertain if these patients are truly iron deficient or functionally iron deficient. I was hoping that prior research might have already answered this question of significance.
Is an exaggerated change a clinically significant finding and how would "exaggerated change" be best defined?
On a deeper level, I wonder about mitochondrial iron metabolism especially in this subset of dialysis patients.
I am revisiting the data on these patients looking for any patterns or clues. However, I was hoping that large data base analysis would have already offered useful insight.
Does the three month testing as suggested by the article reduce the chances of capturing these patients?
In the US, electronic decision support protocols suggest dosing and frequency of parenteral iron prescribing for the overwhelming majority of dialysis patients using the surrogates of ferritin, TSAT and also commonly using elevated hemoglobin cutoff levels. The testing frequency is usually every 30 days with the exception of at least a week post last administration of parenteral iron (which might not be long enough ?)
Also, as mentioned in the article, other markers may not be as practical for broad use. To my knowledge, IV iron prescribing in the US HD population does not usually consider exaggerated response to IV iron (exaggerated change in parameters/markers) beyond the cutoff parameters as set by the algorithm.
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Excerpts from the referenced article:
"Combined use of CHr and high-fluorescence reticulocyte count allowed for very high accuracy in the early prediction of the response to intravenous iron therapy in hemodialysis patients, with a sensitivity of 96% and a specificity of 100% (10). However, neither CHr nor the percentage of hypochromic RBC has the ease of use, cost-effectiveness, and widespread availability of the traditional tests, such as ferritin and TSAT (34)."
"Diagnosis of iron deficiency and guidance of iron supplementation should be made in stable patients with ESRD by ferritin and TSAT measurements at 3-mo intervals."
Clinical Aspects of Iron Use in the Anemia of Kidney Disease
Walter H. Ho ̈rl
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
J Am Soc Nephrol 18: 382–393, 2007. doi: 10.1681/ASN.2006080856
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