There has been no single measure of iron which accurately indicate the patient’s iron status 21. The best available tests are serum ferritin, % hypochromic red cells and transferrin saturation:
• Serum ferritin
− reflects iron stores
− serum ferritin should be interpreted with care in the presence of infection, inflammation or hepatitis and 1 – 2 weeks following blood transfusion or adminstration of intravenous iron
• Transferrin saturation (TSAT)
− reflects availability of iron
− ratio of serum iron to total iron binding capacity multiplied by 100
• Percentage of hypochromic red cells
− also reflects availability of iron
− red cells with Hb concentration < 28g/dl or Hb < 26pg b. Definitions of iron deficiency
• absolute iron deficiency : serum ferritin < 100 ng/ml
• functional iron deficiency : serum ferritin > 100 ng/ml and TSAT < 20% or % hypochromic rbc >10%
c. Iron targets
Table 5.1 Target iron measurements
Test Minimum target Optimal target Maximum level Serum ferritin > 100 ng/ml 200-500 ng/ml > 800 ng/ml
TSAT > 20% 30-40% > 50%
% hypochromic
red cells < 10% < 2.5%
References
1. European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. Guideline 2: Evaluation of anaemia in uraemic patients in. Nephro Dial Transplant 1999:14(Suppl 5):6-7
2. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease: Update 2000. Am J Kidney Dis 2001; 37 Suppl 1:S182-S236
3. Kaufman JS, Reda DJ, Fye CL, Goldfarb DS, Henderson WG, Kleinman JG, Vaamonde CA. Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis. Department of Veterans Affairs Cooperative Study Group on Erythropoietin in Hemodialysis Patients. N Engl J Med 1998;
339(9):578-83
4. Virot JS, Janin G, Guillaumie J, Michel P, Dubot P, Chevet D, Rifle G. Must erythropoietin be injected by the subcutaneous route for every hemodialyzed patient? Am J Kidney Dis 1996; 28(3):400-8
5. Taylor JE, Belch JJ, Fleming LW, Mactier RA, Henderson IS, Stewart WK.
Erythropoietin response and route of administration. Clin Nephrol 1994;41(5):297-302
6. European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. Guideline 9: Route of administration of epoetin.
Nephrol Dial Transplant 1999;14 Suppl 5:19-20
7. Schaller R, Sperschneider H, Thieler H, Dutz W, Hans S, Voigt D, Marx M, Engelmann J, Schoter KH, Scigalla P, et al. Differences in intravenous and subcutaneous application of recombinant human erythropoietin: a multicenter trial. Artif Organs 1994;18(8):552-8
8. Muirhead N, Churchill DN, Goldstein M, Nadler SP, Posen G, Wong C, Slaughter D, Laplante P. Comparison of subcutaneous and intravenous recombinant human erythropoietin for anemia in hemodialysis patients with significant comorbid disease. Am J Nephrol 1992;12(5):303-10
9. Paganini EP, Eschbach JW, Lazarus JM,Van Stone JC, Gimenez LF, Graber SE, Egrie JC, Okamoto DM, Goodkin DA. Intravenous versus subcutaneous dosing of epoetin alfa in hemodialysis patients. Am J Kidney Dis 1995;26(2):331-40 10. De Schoenmakere G, Lameire N, Dhondt A, Van Loo A, Van der Goten J, Duym
P, Vanholder R. The haematopoietic effect of recombinant human erythropoietin in haemodialysis is independent of the mode of administration (i.v. or s.c.).
Nephrol Dial Transplant 1998;13(7):1770-5
11. Jensen JD, Madsen JK, Jensen LW. Comparison of dose requirement, serum erythropoietin and blood pressure following intravenous and subcutaneous erythropoietin treatment of dialysis patients. IV and SC erythropoietin. Eur J Clin Pharmacol 1996;50(3):171-7
12. Casadevall N et al. Pure red-cell aplasia and anti-erythropoietin antibodies in patients treated with recombinant erythropoietin. N Eng J Med 2002;346(7):469-75
13. European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. Target Guideline 5: Target haemoglobin concentration for the treatment of the anaemia of chronic renal failure. Nephro Dial Transplant 1999:14(Suppl 5):11-13
14. Locatelli F, Conte F, Marcelli D. The impact of haematocrit levels and erythropoietin treatment on overall and cardiovascular mortality and morbidity – the experience of the Lombardy Dialysis Registry. Nephrol Dial Transplant 1998;13:1642-4
15. Besarab A, Bolton WK, Browne JK, Egrie JC, Nissenson AR, Okamoto DM, Schwab SJ, Goodkin DA. The effects of normal as compared with low
hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 1998 Aug 27;339(9):584-90
16. Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999;10(3):610-9
17. Madore F, Lowrie EG, Brugnara C, Lew NL, Lazarus JM, Bridges K, Owen WF.
Anemia in hemodialysis patients: variables affecting this outcome predictor. J Am Soc Nephrol 1997;8(12):1921-9
18. Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 1999;10(6):1309-16
19. Canadian Erythropoietin Study Group. Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. BMJ 1990;300(6724):573-8
20. McMahon LP, Johns JA, McKenzie A, Austin M, Fowler R, Dawborn JK.
Haemodynamic changes and physical performance at comparative levels of haemoglobin after long-term treatment with recombinant erythropoietin. Nephrol Dial Transplant 1992;7(12):1199-206
21. McMahon LP, Dawborn JK. Subjective quality of life assessment in hemodialysis patients at different levels of hemoglobin following use of recombinant human erythropoietin. AmJ Nephrol 1992;12(3):162-9
22. Fishbane S, Maesaka JK. Iron management in end-stage renal disease. Am J Kidney Dis 1997;29(3):319-33
23. Kooistra MP, van Es A, Struyvenberg A, Marx JJ. Iron metabolism in patients with the anaemia of end-stage renal disease during treatment with recombinant human erythropoietin. Br J Haematol 1991;79(4):634-9
24. Dunea G, Swagel MA, Bodiwala U, Arruda JA. Intra-dialytic oral iron therapy.
Int J Artif Organs 1994;17(5):261-4
25. Wingard RL, Parker RA, Ismail N, Hakim RM. Efficacy of oral iron therapy in patients receiving recombinant human erythropoietin. Am J Kidney Dis 1995;25(3):433-9
26. Fishbane S, Frei GL, Maesaka J. Reduction in recombinant human erythropoietin doses by the use of chronic intravenous iron supplementation. Am J Kidney Dis 1995;26(1):41-6
27. Anastassiades EG, Howarth D, Howarth J, Shanks D, Waters HM, Hyde K, Geary CG, Yin JA, Gokal R. Monitoring of iron requirements in renal patients on erythropoietin. Nephrol Dial Transplant 1993;8(9):846-53
28. Fishbane S, Frei GL, Maesaka J. Reduction in recombinant human erythropoietin doses by the use of chronic intravenous iron supplementation. Am J Kidney Dis 1995;26(1):41-6
29. Macdougall IC, Tucker B, Thompson J, Tomson CR, Baker LR, Raine AE. A randomized controlled study of iron supplementation in patients treated with erythropoietin. Kidney Int 1996;50(5):1694-29.
30. Sunder-Plassmann G, Horl WH. Importance of iron supply for erythropoietin therapy. Nephrol Dial Transplant 1995; 10(11):2070-6
31. Sepandj F, Jindal K, West M, Hirsch D. Economic appraisal of maintenance parenteral iron administration in treatment of anaemia in chronic haemodialysis patients. Nephrol Dial Transplant 1996;11(2):319-22
32. Silverberg DS, Blum M, Peer G, Kaplan E, Iaina A. Intravenous ferric saccharate as an iron supplement in dialysis patients. Nephron 1996;72(3):413-7
33. Taylor JE, Peat N, Porter C, Morgan AG. Regular low-dose intravenous iron therapy improves response to erythropoietin in haemodialysis patients. Nephrol Dial Transplant 1996;11(6):1079-83
34. Allegra V et al. Iron deficiency in maintenance hemodialysis patients:
assessment of diagnosis criteria and of three different iron treatments. Nephron 1991;57(2):175-82