Anemia management in Haemodialyis patients

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Anemia management in Haemodialyis patients
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Life cycle of RBCs
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Anemia-definition

• Males
• Hb lt 13.5 g/dL in
• Females
• Hb lt 12.0 g/dL in

The Kidney Disease Outcomes Quality Initiative
(KDOQI) (2006)
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Anemia in CKD-Causes

• Erythropoietin deficiency
• Iron deficiency
• RBC life span is shortened(40 to 60 of normal)
• Haemolysis
• Blood loss related to access and dialysis

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Anemia in CKD-Causes

• Inadequate dialysis
• Hyperparathyroidism
• Vitamin B12 or folate deficiency
• Chronic infection or inflammation

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Why anemia treatment is important ?

• Fatigue and impaired cognition
• Increases hospitalization
• Increases mortality
• Left Ventricular Hypertrophy

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When to work up anaemia in CKD patients?

• Males and for post menopausal women
• Haemoglobin lt 12gms, Haematocrit lt 36
• Pre menopausal women and Adolescents
• Haemoglobin lt 11gms, Haematocrit lt 33
• patients on haemodialysis haemoglobin
  concentration to be measured from pre-dialysis
  sample

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
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Anaemia Evaluation

• Hb concentration
• RBC indices / Peripheral smear / Reticulocyte
  count
• Tranferrin saturation
• Stool occult blood
• Stool parasite test

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
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Anaemia Evaluation

• Iron / TIBC / Ferritin
• Serum B12 and red cell folate concentrations
• Differential white blood count
• Tests for haemolysis (hapatoglobin, LDH)
• Serum and / or urine protein electrophoresis
• Bone marrow examination in selected cases

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
11
Anaemia Evaluation

• Assessment of occult gastrointestinal blood loss
• Intact PTH
• Chronic Infections
• Serum Aluminium
• adequacy of dialysis to be assessed

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
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Iron deficiency

• True iron deficiency
• caused by blood loss and/or not receiving enough
  iron.
• Lab values Tsat lt 20 and ferritin lt 200.
• Functional iron deficiency
• Not enough iron is delivered to the marrow.
• Lab values falling Tsat and rising ferritin.

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KDOQI (2006) targets for patients on dialysis

• Transferrin saturation (Tsat) gt 20, no upper
  limit specified
• Ferritin lower limit gt 200 ng/mL.
• Ferritingt500 ng/ml not routinely recommended.

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Treatment of Anemia with Iron

• IV administration of iron is an optimum route of
  delivery of iron in HD patients
• Oral iron is poorly absorbed.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
19
IV Iron dose

• To correct iron deficiency 
• 1 gram IV iron in divided doses
• 100 mg doses of iron sucrose injection on 10
  consecutive dialysis sessions 
• Reassess iron status and repeat if necessary.
• Maintenance Treatment 
• Smaller doses administered at regular intervals
  to maintain iron status within target. 
• The average IV iron dose needed to maintain a
  stable ferritin level appears to be in the range
  of 22 to 65 mg/week.

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History of IV iron in renal anemia

• The regular use of colloidal IV iron preparations
  in the treatment of the anemia of ESRD patients
  on maintenance hemodialysis was first reported in
  1967
• After the beginning of the erythropoietin era, IV
  iron was continued
• 1993 very low erythropoietin requirements in a
  series of patients on maintenance hemodialysis
  was reported with use of IV iron
• Iron sucrose was approved for use by the US FDA
  in November 2000

Shaldon S. The use of IV iron in the treatment of
anaemia of ESRD patients on maintenance
haemodialysis an historical and personal view.
Nephrol Dial Transplant (2007) 22 2325.
21
Problems in anemia management in CKD

• Common challenges faced are
• Maintenance of stable hemoglobin levels in their
  patients
• Avoid overshooting Hb targets
• Balance intravenous iron EPO
• Improve EPO response to use the lowest effective
  EPO dose
• A major concern is EPO hyporesponsiveness
  insufficient iron replacement
• IV iron is important in managing these challenges
  to a large extent

Kapoian T. Challenge of effectively using
erythropoiesis-stimulating agents and intravenous
iron. Am J Kidney Dis. 2008 Dec52(6
Suppl)S21-8.
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IV iron in CKD

• IV iron therapy is superior to oral iron
  supplementation in CKD
• Risk factors associated with IV iron therapy
  include acute allergic reactions as well as
  long-term complications caused by the generation
  of powerful oxidant species, initiation and
  propagation of lipid peroxidation
• Allergy is to related to dextran moiety
• Iron dextran is associated with higher incidence
  of Type I hypersensitivity than Iron sucrose
• Iron sucrose carries the lowest risk for
  hypersensitivity

1. Horl WH. Iron therapy for renal anemia how
much needed, how much harmful? Pediatr Nephrol
2007224809.
23
Iron sucrose in kidney disease

• Iron deficiency may be corrected by oral iron
  supplementation but it is limited by
• Poor compliance
• Adverse gastrointestinal reactions
• IV iron preparations commonly used include iron
  sucrose, sodium ferric gluconate, iron dextran
• Iron sucrose is safer than iron dextran, is
  generally considered a safe and effective IV iron
  preparation in renal anemia

1. Li H. Intravenous iron sucrose in peritoneal
dialysis patients with renal anemia. Peritoneal
Dialysis International 20082814954.
24
Iron sucrose in kidney disease

• Iron sucrose is a novel and effective addition in
  the management of Anemia related to kidney
  diseases
• Iron Sucrose is elemental iron which replenishes
  body iron stores in patients with iron deficiency
  
• Approximately 25 of hemodialysis patients can be
  maintained on oral iron supplementation the
  others require IV iron supplementation

1. Dennis J. Cada. Iron Sucrose Injection. Drug
Reviews From The Formulary, Volume 36, April
2001,404-412 2. W.H. Horl, OPTA-therapy with iron
and erythropoiesis-stimulating agents in chronic
kidney disease, nephrology dial transplant. 2007
suppl 3iii2-iii6
25
Indications

• IV iron sucrose is indicated in
• Non-Dialysis Dependent - Chronic Kidney Disease
  (NDD-CKD) patients receiving an erythropoietin
• Non-Dialysis Dependent - Chronic Kidney Disease
  (NDD-CKD) patients not receiving an
  erythropoietin
• Hemodialysis Dependent - Chronic Kidney Disease
  (HDD-CKD) patients receiving an erythropoietin
• Peritoneal Dialysis Dependent - Chronic Kidney
  Disease (PDD-CKD) patients receiving an
  erythropoietin

1. Venofer package insert. Shirley, NY
American Regent, Inc. 2007. 2. Hollands JM et
al. Safety of High-Dose Iron Sucrose Infusion in
Hospitalized Patients With Chronic Kidney
Disease. Am J Health-Syst Pharm.
 200663(8)731-734. 3. Mircescu G et al.
Intravenous iron supplementation for the
treatment of anaemia in pre-dialyzed chronic
renal failure patients. Nephrol Dial Transplant
200621120-4.
26
Iron sucrose in pre-dialysis CRF patients

• Patients undergoing chronic hemodialysis often
  present with anemia
• IV iron therapy is administered in conjunction
  with EPO as it helps prevent EPO-hypo-responsivene
  ss
• Study evaluated use of Iron sucrose in pre
  dialyzed patients of CRF
• 60 non-diabetic CRF patients were included in the
  study

Mircescu G ,et al. Intravenous iron
supplementation for the treatment of anaemia in
pre-dialyzed chronic renal failure patients.
Nephrol Dial Transplant 200621120-4.
27
Results

• 60 patients included in the study
• 58 of patients reporting a rise in Hb gt 1 g/dL
  vs. baseline in the study
• 80 of patients had a Hb gt 10 g/dL vs. 44 at
  baseline
• 55 had a Hb gt 11 g/dL vs. 0 at baseline
• Mean serum iron concentration increased from
• 73.9 µg/dL at baseline
• 84.2 µg/dL at 6 months
• 101.8 µg/dL at 12 months of therapy
• No worsening of renal function, and no adverse
  events were reported

Mircescu G et al. Intravenous iron
supplementation for the treatment of anaemia in
pre-dialyzed chronic renal failure patients.
Nephrol Dial Transplant 200621120-4.
28
Efficacy of Iron sucrose in hemodialysis patients

• Schiesser et al conducted a prospective
  multicentre clinical trial in 50 iron-replete
  hemodialysis patients to evaluate the efficacy of
  iron sucrose administration for 6 months
• Hb level remained stable (121.1 at baseline
  12.11.5 g/dl at the end of the study)
• Reduced dose for EPO

Schiesser et al. Weekly low-dose treatment with
intravenous iron sucrose maintains iron status
and decreases epoetin requirement in iron-replete
haemodialysis patients. Nephrol Dial Transplant
(2006) 21 28415.
29
Results of Schiesser et al study

• Hb level remained stable (121.1 at baseline
  12.11.5 g/dl at the end of the study)
• Red cell parameters remained stable

Schiesser et al. Weekly low-dose treatment with
intravenous iron sucrose maintains iron status
and decreases epoetin requirement in
iron-replete haemodialysis patients. Nephrol Dial
Transplant (2006) 21 28415.
30
Iron sucrose IV reduces EPO demand in dialysis
patients

• In the study of Iron sucrose in hemodialysis
  patients conducted by Schiesser et al the dosage
  for the three different epoetins decreased by
• 38.5 with darbepoetin alfa
• 6.3 with epoetin alfa
• 8.3 with epoetin beta

Schiesser et al. Weekly low-dose treatment with
intravenous iron sucrose maintains iron status
and decreases epoetin requirement in iron-replete
haemodialysis patients. Nephrol Dial Transplant
(2006) 21 28415.
31
Results showing reduced EPO need with iron sucrose

• Schiesser et al showed reduced EPO need with low
  dose maintenance iron sucrose in their study

Schiesser et al. Weekly low-dose treatment with
intravenous iron sucrose maintains iron status
and decreases epoetin requirement in
iron-replete haemodialysis patients. Nephrol Dial
Transplant (2006) 21 28415.
32
IV iron reduces EPO demand in dialysis patients

• Chang et al studies the beneficial effects of 2
  weekly IV iron supplementation compared to once
  monthly IV iron in 149 iron replete patients
• EPO requirement reduced by 25 when sereum
  ferritin Transferrin saturation was maintained
  at high levels by administering 2 weekly IV iron
  compared to IV iron given once monthly
• Significant decrease in serum albumin,
  cholesterol pre-dialysis creatinine when IV
  iron was administered 2 weekly for 1 year

Chang CH et al. Reduction in erythropoietin doses
by the use of chronic intravenous iron
supplementation in iron-replete hemodialysis
patients. Clin Nephrol. 200257136-41.
33
IV iron reduces EPO demand in dialysis patients
Results from Meta analysis

• Compared to oral iron IV iron preparations
  significantly reduce the EPO requirement in
  dialysis patients

Rozen-Zvi et al. Intravenous Versus Oral Iron
Supplementation for the Treatment of Anemia in
CKD Systematic Review and Meta-analysis.
American Journal of Kidney Diseases
200852897-906.
34
Iron sucrose in CKD patients not on dialysis

• Charytan et al compared oral iron with Iron
  sucrose in 96 NDD-CKD patients
• More IV iron patients (54.2) attained hemoglobin
  values gt 11.0 g/dl compared to oral iron patients
  (31.3)
• There were no serious side effects with iron
  sucrose

Charytan C et al. Comparison of intravenous iron
sucrose to oral iron in the treatment of anemic
patients with chronic kidney disease not on
dialysis. Nephron Clin Pract. 2005100(3)c55-62.
35
Efficacy safety of Iron sucrose in peritoneal
dialysis patients

• Li et al conducted a study to compare the
  clinical outcomes safety of IV iron sucrose
  oral ferrous succinate in combination with rHuEPO
  therapy in patients on maintenance PD
• 46 patients were included 26 received iron
  sucrose 20 oral iron
• Hb Hct increased significantly at 2 weeks in
  the IV group compared with baseline
• The total response rate at 8 weeks was 94.8 for
  the IV group - significantly higher than that of
  the oral group (55.0)
• There were no adverse events with IV iron
• 8 patients in the oral group had adverse GI
  effects

Li H. Intravenous iron sucrose in peritoneal
dialysis patients with renal anemia. Peritoneal
Dialysis International 20082814954.
36
Results of Iron sucrose in PD patients contd.

• Response rates to IV iron sucrose therapy
  compared to Oral iron therapy

Li H. Intravenous iron sucrose in peritoneal
dialysis patients with renal anemia. Peritoneal
Dialysis International 20082814954.
37
Efficacy of Iron sucrose in ESRD

• Iron sucrose in apparently iron-replete patients
  will decrease the EPO requirements for a given
  target hematocrit in patients on maintenance
  hemodialysis with end-stage renal disease (ESRD)

1. Schiesser et al. Weekly low-dose treatment
with intravenous iron sucrose maintains iron
status and decreases epoetin requirement in
iron-replete haemodialysis patients. Nephrol Dial
Transplant (2006) 21 28412845. 2. Shaldon S.
The use of IV iron in the treatment of anaemia of
ESRD patients on maintenance haemodialysis an
historical and personal view. Nephrol Dial
Transplant (2007) 22 2325.
38
Safety of Iron sucrose

• Aronoff et al studied the safety of iron sucrose
  in hemodialysis patients
• 665 hemodialysis patients with 80 who had
  experienced previous intolerance to other IV iron
  preparations were given iron sucrose
• There were no serious or life-threatening
  drug-related adverse events

Aronoff GR et al. Iron sucrose in hemodialysis
patients Safety of replacement and maintenance
regimens. Kidney International, 20046611938.
39
Iron sucrose in patients hypersensitive to iron
dextran

• Iron dextran has been the only available
  parenteral iron preparation for a long time
• Its use has been associated with increased risk
  of allergic reactions, even after reaction-free
  previous use

Haddad A et al. Use of Iron Sucrose in Dialysis
Patients Sensitive to Iron Dextran. Saudi J
Kidney Dis Transpl 200920(2)208-211
40
Iron sucrose in patients hypersensitive to iron
dextran

• Of 205 patients of hemodialysis, 7.3 were
  hypersensitive
• Hypersensitive patients were given iron sucrose
  for 8 weeks
• None of them developed hypersensitivity
• Mean hematocrit increased from 23.8 to 32.27
• Mean serum iron increased from 29.3 ng/dL to 76.8
  ng/dL

Haddad A et al. Use of Iron Sucrose in Dialysis
Patients Sensitive to Iron Dextran. Saudi J
Kidney Dis Transpl 200920(2)208-211
41
Safety of Iron sucrose compared to other iron
preparations

• Rates of life-threatening ADEs
• 0.6 per million for iron sucrose
• 0.9 per million for sodium ferric gluconate
  complex
• 3.3 per million for lower molecular weight iron
  dextran
• 11.3 per million per million for higher molecular
  weight iron dextran

Chertow GM et al. Update on adverse drug events
associated with parenteral iron. Nephrol Dial
Transplant (2006) 21 378382.
42
Dosing and administration

• NDD-CKD - Administered as a total cumulative dose
  of 1,000 mg over a 14 days as a 200 mg slow IV
  injection undiluted over 2 to 5 minutes on 5
  different occasions
• HDD-CKD - Administered undiluted as a 100 mg slow
  IV over 2 to 5 minutes or as an infusion of 100
  mg, diluted in a maximum of 100 mL of NS over 15
  minutes per consecutive hemodialysis session for
  a total cumulative dose of 1,000 mg

1. Venofer package insert. Shirley, NY
American Regent, Inc. 2007.
43
Dosing and administration contd.

• PDD-CKD - Administered undiluted as a total
  cumulative dose of 1,000 mg in 3 divided doses,
  given by slow IV infusion, over 28 days
• 2 infusions of 300 mg over 1.5 hs 14 days apart
• Followed by 1 400 mg infusion over 2.5 h 14 days
  later
• Should be diluted in 250 mL of NS
• Low maintenance doses in hemodialysis patients
  include 50mg injected into the venous limb of the
  haemodialysis tubing system (slow intravenous
  push at a rate of 10 mg/min)

1. Venofer package insert. Shirley, NY
American Regent, Inc. 2007.
44
Dosing and administration contd.

• The usual dose is 100 mg administered one to
  three times per week.
• Most patients will require a minimum cumulative
  dose of 1000 mg of elemental iron administered
  over 10 sequential dialysis sessions to achieve a
  favorable response
• Patients may continue to receive IV iron therapy
  at the lowest dose necessary to maintain target
  levels of hemoglobin, hematocrit iron storage
  parameters

Cada DJ. Iron Sucrose Injection. Hospital
Pharmacy 20013640412.
45
Monitoring parameters

• Patients receiving regular IV iron therapy
  require monitoring of hematologic parameters
  iron indices (Hb, Hct, TSAT, ferritin)
• Maintain TSAT between 20 and 50
• Iron therapy should be withheld in patients with
  TSAT 50
• Iron therapy should be withheld in patients with
  ferritin values 800 ng/mL
• Since transferrin saturation values increase
  rapidly after IV administration of iron sucrose,
  serum iron values may be reliably obtained 48
  hours after IV iron sucrose dosing

Cada DJ. Iron Sucrose Injection. Hospital
Pharmacy 20013640412.
46
Anemia management in CKD NKF K/DOQI GUIDELINES

• Both iron EPO need to be given
• Most patients need IV iron
• Iron deficiency is detected when TSAT is lt20 and
  the serum ferritin is lt100 ng/mL
• Withhold IV iron if TSAT is 50 Ferritin is
  800ng/ml

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Monitoring iron stores in CKD

• During initiation of EPO increased dose
• TSAT / serum ferritin to be checked every month
  in patients not receiving IV iron or once in
  three months in those receiving IV iron .
• Once target Hb achieved
• Check iron stores once in 3 months

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
48
When should IV iron be discontinued?

• IV iron should be discontinued when TSAT is gt50
  and Ferritin is gt 800ng / ml.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
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Initiation of Erythropoietin

• Hb lt12g/dl documented 2 weeks apart with minimum
  two hemoglobin estimations.
• EPO therapy should be initiated only after
  correcting iron, Vitamin B12 and Folic acid
  deficiency, and other possible factors
  contributing to anaemia.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
51
Treatment with Erythropoietin

• EPO should be started at a dose of 80 -120IU/Kg
  / week.
• IV administration preferred in HD patients
• Once the target Hb is achieved, Hb monitoring
  should be performed once every month

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
52
Treatment with Erythropoietin

• 1gm/dl rise in Hb is necessary with EPO therapy
  at the end of 2 weeks.
• EPO dosage can be increased by 50 till the
  target Hb is achieved.
• If the rise in Hb is gt 1.5Gms at the end of 2
  weeks, the dose of EPO to be reduced by 25

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
53
KDOQI (2006) targets for patients on dialysis

• Hemoglobin (Hb) gt 11 g/dL, caution when
  intentionally maintaining Hb 13 g/dL.

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Inadequate response to EPO

• Most common causes
• iron deficiency
• non-compliance to EPO therapy
• Dialysis inadequacy

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
55
Inadequate response to EPO

• Other causes
• Folate or Vitamin B 12 deficiency
• Chronic blood loss
• Infection / inflammation (e.g., access
  infections, surgical inflammation, AIDS, SLE,
  Occult Tuberculosis/Chronic Malaria / Kalazar)
• Malnutrition, Hemolysis, Hyperparathyroidism,
  Aluminium toxicity
• Haemoglobinopathies
• Multiple myeloma other malignancies. Use of
  ACE-1 / ARB agents

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
56
Adequacy of Dialysis

• During thrice weekly maintenance haemodialysis
  KT/V of gt1.2 is to be achieved to ensure optimal
  dialysis.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
57
Resistance to EPO

• Failure to achieve target Hb concentration while
  receiving more than 300IU/kg/week and continued
  need for such dosage to maintain target in
  presence of adequate iron stores and absence of
  functional deficiency of iron.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
58
Pure Red Cell Aplasia

• Suspect pure red cell aplasia
• In patients treated with EPO gt 4 weeks who
  develop sudden and rapid decline in Hb
  concentration gt 0.5 - 1 g/dl/week. Or requires
  transfusion of 1 - 2 units of red cells with
  normal platelets and white cell counts, in the
  absence of any other obvious clinical cause.
• Confirmation of diagnosis
• Severe non regenerative anaemia with erythroid
  hypoplasia of the bone marrow and normal
  cellularity of the other elements.
• Less than 5 erythroblasts in the marrow with
  evidence of red cell precursor block.
• Demonstration of anti erythropoietin antibodies
  in the patients serum.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
59
Adjuvant Therapies for treatment of anaemia

• L-carnitine
• L-carnitine may enhance response to Epoetin when
  used as adjuvant.
• Vitamins
• Oral vitamin E 1200IU given 6 hrs before a HD
  session along with intensive iron may protect
  patients against oxidative stress related
  diseases.
• Hypo responsiveness to EPO therapy can be reduced
  by correcting depleted vitamin C levels
  administered along with vitamin E

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
60
Red Cell Transfusions in CKD

• Transfusions should be avoided as far as
  possible.
• Indications for transfusion are
• Severely anaemic patient with recognized symptoms
  or signs of anaemia. (acute blood loss with
  angina / haemodynamic instability)
• EPO resistant patient with chronic blood loss
• If transfusion is mandatory in patients for renal
  transplant, use leucocyte filters and irradiated
  blood.

Best Practice Guidelines for management of Renal
Anaemia, Indian J Nephrol 200515, Supplement 1
S32-S41
61
Other indications for Iron Sucrose
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Selective Use of Recombinant Human Erythropoietin
in Pregnant Patients with Severe Anemia or
Nonresponsive to Iron Sucrose Alone

• Krafft A, Bencaiova G, Breymann C.
• Feto-Maternal Hematology Group, Division of
  Obstetrics, Department of Obstetrics and
  Gynecology, University Hospital Zurich, Zurich,
  Switzerland.
• This study shows an effective treatment regimen
  for patients with various degrees of anemia in
  pregnancy.
• Iron sucrose is a safe and effective treatment
  option.
• In cases of severe iron deficiency anemia or poor
  response to parenteral iron therapy additional
  administration of rhEPO might be considered.
• However, the mechanism for not responding to
  intravenous iron therapy despite iron deficiency
  anemia still remains unclear to a large extent.

63
Efficacy and safety of intravenously administered
iron sucrose with and without adjuvant
recombinant human erythropoietin for the
treatment of resistant iron-deficiency anemia
during pregnancy

• Breymann C, Visca E, Huch R, Huch A.
• Department of Obstetrics and Gynecology, the
  Clinic of Obstetrics, and the Division of
  Perinatal Physiology, University of Zurich,
  Switzerland.
• Adjuvant recombinant human erythropoietin safely
  enhanced the efficacy of iron sucrose in the
  treatment of gestational iron-deficiency anemia
  resistant to orally administered iron alone.

64
A randomized, double-blind, placebo controlled,
multi-center study of intravenous iron sucrose
and placebo in the treatment of restless legs
syndrome

• Grote L, Leissner L, Hedner J, Ulfberg J.
• Sleep Disorders Center, Department of
  Pulmonary Medicine, Sahlgrenska University
  Hospital, Gothenburg, Sweden.
• This study showed a lack of superiority of iron
  sucrose at 11 weeks but found evidence that iron
  sucrose reduced RLS symptoms both in the acute
  phase (7 weeks) and during long-term follow up in
  patients with variable degree of iron deficiency.
  
• Further studies on target patient groups, dosing
  and dosing intervals are warranted before iron
  sucrose could be considered for treatment of iron
  deficient patients with RLS.

65
Safety and usefulness of intravenous iron sucrose
in the management of preoperative anemia in
patients with menorrhagia a phase IV,
open-label, prospective, randomized study

• Kim YH, Chung HH, Kang SB, Kim SC, Kim YT.
• Department of Obstetrics and Gynecology,
  College of Medicine, Seoul National University,
  Seoul, Korea.
• Preoperative intravenous iron sucrose
  administration is more effective than oral iron
  and is as safe as oral iron therapy in the
  correction of preoperative anemia due to
  menorrhagia.

66
Intravenous iron sucrose is superior to oral iron
sulphate for correcting anaemia and restoring
iron stores in IBD patients A randomized,
controlled, evaluator-blind, multicentre study

• Lindgren S, Wikman O, Befrits R, Blom H,
  Eriksson A, Granno C, Ung KA, Hjortswang H,
  Lindgren A, Unge P.
• Department of Medicine, Gastroenterology-Hepa
  tology Division, University Hospital MAS, Malmo.
• Treatment with intravenous iron sucrose is
  effective, safe, well tolerated and superior to
  oral iron in correcting haemoglobin and iron
  stores in patients with IBD.

67
Usefulness of the administration of intravenous
iron sucrose for the correction of preoperative
anemia in major surgery patients

• Muñoz M, García-Erce JA, Díez-Lobo AI, Campos
  A, Sebastianes C, Bisbe E Anaemia Working Group
  España (AWGE).
• Because of the low incidence of side effects and
  the rapid increase of hemoglobin levels, IVIS
  emerges as a safe, effective drug for treating
  preoperative anemia in surgery patient
  populations.

68
Efficacy and safety of intravenous iron sucrose
therapy in a group of children with iron
deficiency anemia

• Pinsk V, Levy J, Moser A, Yerushalmi B,
  Kapelushnik J.
• Pediatric Day Care Unit, Soroka University
  Medical Center, Faculty of Health Sciences,
  Ben-Gurion University of the Negev, Beer Sheva,
  Israel.
• These preliminary data suggest that
  administration of intravenous iron sucrose in
  pediatric patients is well tolerated and has a
  good clinical result, with minimal adverse
  reactions.

69
A 12-week randomised study comparing intravenous
iron sucrose versus oral ferrous sulphate for
treatment of postpartum anemia.

• Westad S, Backe B, Salvesen KA, Nakling J,
  Økland I, Borthen I, Rognerud Jensen OH, Kolås T,
  Løkvik B, Smedvig E.
• Department of Obstetrics and Gynecology,
  Innlandet Hospital Trust, Lillehammer, Norway.
  stian.westad_at_sykehuset-innlandet.no
• Women who received 600 mg intravenous iron
  sucrose followed by standard oral iron after four
  weeks, replenished their iron stores more rapidly
  and had a more favorable development of the
  fatigue score indicating improved quality of life.

70
A phase III randomized controlled study comparing
iron sucrose intravenously (IV) to no iron
treatment of anemia in cancer patients undergoing
chemotherapy and erythropoietin stimulating agent
(ESA) therapy

• R. E. Bellet, H. Ghazal, M. Flam, A.
  Drelichman, N. Gabrail, D. Woytowitz, D. Loesch,
  D. Niforos, A. Mangione, L. Anthony and Iron
  Sucrose Study Group
• IV iron sucrose increased Hgb levels and iron
  stores significantly and is well tolerated in
  doses up to 500 mg increments in ESA treated
  patients with cancer chemotherapy- related
  anemia.
• IV iron sucrose should be considered in
  combination with erythropoietic therapy in anemic
  cancer patients receiving chemotherapy.

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Summary

• Iron (blood) losses are high in HD patients
• Regular use of intravenous (IV) iron improves
  sensitivity to Erythropoietin
• maintain TSAT gt20 and ferritin gt200 ng/mL
• Adequate and appropriate dosing of Erythropoietin
  is necessary
• Aim for Hemoglobin (Hb) gt 11 g/dL, caution when
  intentionally maintaining Hb 13 g/dL.

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Key points

• Anemia in CKD patients is common
• EPO therapy forms the mainstay of treatment
• EPO therapy alone may be ineffective unless
  supplemented by iron
• Oral iron supplementation has problems of
  intolerance
• IV iron forms the best adjunct with EPO in CKD
  patients

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Key points

• IV iron sucrose is one of the iron preparations
• It is indicated in hemodialysis patients, non
  hemodialysis patients with or without EPO and
  peritoneal dialysis patients
• Efficacy is proved in each of these indications
• Low maintenance dose of Iron sucrose keeps Hb and
  Hct stable in hemodialysis patients

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Key points

• Iron sucrose administration along with EPO
  reduces the dose requirement of EPO
• Iron sucrose can be safely given to patients
  hypersensitive to iron dextran
• Iron sucrose is safer than other IV iron
  preparations

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Thank You