Maintaining a serum ferritin level of 600 to 700 ng/mL using approximately 200 mg/mo intravenous (IV) iron can decrease erythropoietin dose requirements in maintenance hemodialysis (HD) patients with functional iron deficiency anemia, Kearkiat Praditpornsilpa, MD, of Chulalongkorn University in Bangkok, Thailand, and colleagues reported in the Canadian Journal of Kidney Health and Disease.

Investigators randomly assigned 200 patients receiving HD who had hemoglobin concentrations of 8 to 12 g/dL, transferrin saturation of less than 30%, and serum ferritin of 200 to 400 ng/mL to a low-serum ferritin group (to maintain serum ferritin of 200 to 400 ng/mL) or a high-serum ferritin group (to increase serum ferritin to 600 to 700 ng/mL). During a 6-week titration period, patients in the high-serum ferritin group received a total IV iron dose of 600 mg (100 mg/wk), while the low-serum ferritin group received no iron. During a 6-month follow up period, IV iron was prescribed to maintain the target ferritin range for each group. The dose of erythropoiesis-stimulating agents (ESAs) was also adjusted to maintain target hemoglobin levels of 10 to 12 g/dL.

The erythropoietin resistance index (ERI) declined significantly in the high-serum ferritin group compared with the low-serum ferritin group after receiving IV iron during the 6-week titration period (mean difference: −113.43 vs 41.08 unit/wk/g/dL) and 3-month follow-up period (mean differences −88.88 vs −10.48 unit/wk/g/dL), the investigators reported. Over 6 months, the ERI had declined from 853.96 to 765.34 unit/week/g/dL in the highserum ferritin group. Mean IV iron dose was 108.3 mg/mo in the low-serum ferritin group and 192.3 mg/mo in the high-serum ferritin group. Mean serum ferritin was 367.0 ng/mL and 619.6 ng/mL, respectively.

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“The present study emphasized the benefit of IV iron in patients with functional iron deficiency anemia, whereas the PIVOTAL [Proactive IV irOn Therapy in hemodiALysis patients] study showed the benefit of IV iron in absolute iron deficiency anemia,” Dr Praditpornsilpa’s team explained. “Furthermore, the PIVOTAL study prescribed IV iron as a bolus regimen, so IV iron had to be stopped in some patients due to a very high serum ferritin level. On the contrary, in the present study, IV iron was given as a maintenance protocol to avoid overshooting of serum ferritin and subsequent iron toxicity.”

With respect to adverse events, 7 patients in each group died from sudden cardiac arrest or congestive heart failure, possibly due to their baseline cardiovascular status. The mean serum ferritin at death was 315.3 ng/mL in the lowserum ferritin group and 828.86 ng/mL in the  high-serum ferritin group. The IV iron supplement was scheduled as a maintenance protocol as twice a month and once a month, which may explain the lack of serious adverse events, according to the authors.


Susantitaphong P, Siribumrungwong M, Takkavatakarn K, et al. Effect of maintenance intravenous iron treatment on erythropoietin dose in chronic hemodialysis patients: a multicenter randomized controlled trial. Can J Kidney Health Dis. 7:1-10. doi:  10.1177/2054358120933397