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Anemia management in Haemodialyis patients. Life cycle of RBCs.

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Presentation on theme: "Anemia management in Haemodialyis patients. Life cycle of RBCs."— Presentation transcript:

1 Anemia management in Haemodialyis patients

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3 Life cycle of RBCs

4 Anemia-definition Males: Hb < 13.5 g/dL in Females: Hb < 12.0 g/dL in The Kidney Disease Outcomes Quality Initiative (KDOQI) (2006)

5 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

6 Anemia in CKD-Causes Inadequate dialysis Hyperparathyroidism Vitamin B12 or folate deficiency Chronic infection or inflammation

7 Why anemia treatment is important ? Fatigue and impaired cognition Increases hospitalization Increases mortality Left Ventricular Hypertrophy

8 When to work up anaemia in CKD patients? Males and for post menopausal women  Haemoglobin < 12gms%, Haematocrit < 36% Pre menopausal women and Adolescents  Haemoglobin < 11gms%, Haematocrit < 33% patients on haemodialysis haemoglobin concentration to be measured from pre-dialysis sample Best Practice Guidelines for management of Renal Anaemia, Indian J Nephrol 2005;15, Supplement 1: S32-S41

9 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 2005;15, Supplement 1: S32-S41

10 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 2005;15, 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 2005;15, Supplement 1: S32-S41

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

17 KDOQI (2006) targets for patients on dialysis Transferrin saturation (Tsat) > 20%, no upper limit specified Ferritin lower limit > 200 ng/mL. Ferritin>500 ng/ml not routinely recommended.

18 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 2005;15, 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.

20 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: 23–25.

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 Dec;52(6 Suppl):S21-8.

22 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 2007;22:480–9.

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 2008;28:149–54.

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, W.H. Horl, OPTA-therapy with iron and erythropoiesis-stimulating agents in chronic kidney disease, nephrology dial transplant suppl 3;iii2-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.; Hollands JM et al. Safety of High-Dose Iron Sucrose Infusion in Hospitalized Patients With Chronic Kidney Disease. Am J Health-Syst Pharm. 2006;63(8): Mircescu G et al. Intravenous iron supplementation for the treatment of anaemia in pre-dialyzed chronic renal failure patients. Nephrol Dial Transplant 2006;21:120-4.

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- responsiveness 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 2006;21:120-4.

27 Results 60 patients included in the study 58% of patients reporting a rise in Hb > 1 g/dL vs. baseline in the study 80% of patients had a Hb > 10 g/dL vs. 44% at baseline 55% had a Hb > 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  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 2006;21:120-4.

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 (12±1.1 at baseline & 12.1±1.5 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: 2841–5.

29 Results of Schiesser et al study Hb level remained stable (12±1.1 at baseline & 12.1±1.5 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: 2841–5.

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: 2841–5.

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: 2841–5.

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. 2002;57:

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 2008;52:

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 > 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. 2005;100(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 2008;28:149–54.

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 2008;28:149–54.

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: 2841– 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: 23–25.

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, 2004;66:1193–8.

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 2009;20(2):

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 2009;20(2):

41 Safety of Iron sucrose compared to other iron preparations Rates of life-threatening ADEs – per million for iron sucrose per million for sodium ferric gluconate complex per million for lower molecular weight iron dextran 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: 378–382.

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 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 2001;36:404–12.

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 2001;36:404–12.

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 <20% and the serum ferritin is <100 ng/mL Withhold IV iron if TSAT is ≥50% & Ferritin is ≥ 800ng/ml

47 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 2005;15, Supplement 1: S32-S41

48 When should IV iron be discontinued? IV iron should be discontinued when TSAT is >50% and Ferritin is > 800ng / ml. Best Practice Guidelines for management of Renal Anaemia, Indian J Nephrol 2005;15, Supplement 1: S32-S41

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50 Initiation of Erythropoietin Hb <12g/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 2005;15, Supplement 1: S32-S41

51 Treatment with Erythropoietin EPO should be started at a dose of IU/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 2005;15, 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 > 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 2005;15, Supplement 1: S32-S41

53 KDOQI (2006) targets for patients on dialysis Hemoglobin (Hb) > 11 g/dL, caution when intentionally maintaining Hb 13 g/dL.

54 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 2005;15, 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 2005;15, Supplement 1: S32-S41

56 Adequacy of Dialysis During thrice weekly maintenance haemodialysis KT/V of >1.2 is to be achieved to ensure optimal dialysis. Best Practice Guidelines for management of Renal Anaemia, Indian J Nephrol 2005;15, 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 2005;15, Supplement 1: S32-S41

58 Pure Red Cell Aplasia Suspect pure red cell aplasia In patients treated with EPO > 4 weeks who develop sudden and rapid decline in Hb concentration > g/dl/week. Or requires transfusion of 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 2005;15, 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 2005;15, 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 2005;15, Supplement 1: S32-S41

61 Other indications for Iron Sucrose

62 Fetal Diagn Ther 2009 June 5;25(2): Selective Use of Recombinant Human Erythropoietin in Pregnant Patients with Severe Anemia or Nonresponsive to Iron Sucrose Alone Krafft A, Bencaiova G, Breymann C.Krafft ABencaiova GBreymann 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 Am J Obstet Gynecol 2001 Mar;184(4):662-7 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.Breymann CVisca EHuch RHuch 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 Moy Disord 2009 June 1 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.Grote LLeissner LHedner JUlfberg 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 Acta Haematol 2009;121(1):37-41 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.Kim YHChung HHKang SBKim SCKim 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 Scand J Gastroenterol 2009 Mar 27:1-8 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.Lindgren SWikman OBefrits RBlom HEriksson AGranno CUng KA Hjortswang HLindgren AUnge P Department of Medicine, Gastroenterology-Hepatology 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 Med Clin (Barc) 2009 Mar7;132(8):303-6 Usefulness of the administration of intravenous iron sucrose for the correction of preoperative anemia in major surgery patients Mu ñ oz M, Garc í a-Erce JA, D í ez-Lobo AI, Campos A, Sebastianes C, Bisbe E; Anaemia Working Group Espa ñ a (AWGE). Mu ñ oz MGarc í a-Erce JAD í ez-Lobo AICampos ASebastianes CBisbe EAnaemia Working Group Espa ñ a (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 Isr Med Assoc J 2008 May;10(5):335-8 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.Pinsk VLevy JMoser AYerushalmi BKapelushnik 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 Acta Obstet Gynecol Scand 2008;87(9): 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.Westad SBacke BSalvesen KANakling JØkland IBorthen I Rognerud Jensen OHKolås TLøkvik BSmedvig E Department of Obstetrics and Gynecology, Innlandet Hospital Trust, Lillehammer, Norway. 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 Journal of Clinical Oncology, 2007,Vol 25, No.18S,9109 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.

71 Summary Iron (blood) losses are high in HD patients Regular use of intravenous (IV) iron improves sensitivity to Erythropoietin maintain TSAT >20% and ferritin >200 ng/mL Adequate and appropriate dosing of Erythropoietin is necessary Aim for Hemoglobin (Hb) > 11 g/dL, caution when intentionally maintaining Hb 13 g/dL.

72 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

73 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

74 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

75 Thank You


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