From ASN 2008: Use of IV Iron in CKD Patients
From ASN 2008: Use of IV Iron in CKD Patients
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Discuss From ASN 2008: Use of IV Iron in CKD Patients
Jeffrey S. Berns, MD: Hello. I'm Jeffrey Berns, Professor of Medicine, Pediatrics, at the University of Pennsylvania School of Medicine in Philadelphia, and Editor-in-Chief of Medscape Nephrology.
I recently chaired a session at the American Society of Nephrology meeting here at Philadelphia on iron, and wanted to comment upon a couple of things that I learned and heard at that meeting.
First, there is clear evidence that IV iron has toxicity, both systemically and in the kidneys. This seems to be mediated by a variety of factors, including inflammatory changes, but there have also been identified changes in DNA and histones and so forth. Clearly, there is potential for significant toxicity -- in experimental animals, though; this hasn't been clearly carried over in humans. I think that still remains uncertain.
There was some discussion about the value of serum ferritin levels, particularly on the high end -- whether these were at all useful in clinical practice. The panelists, as well as members of the audience, raised serious questions as to whether there's any predictive value at all for either efficacy of additional iron or toxicity with serum ferritin levels above 500 or 800 or 1200. Nobody really seems to know what upper limit of ferritin is important for us.
Lastly, there was a fair amount of discussion about different intravenous iron preparations. There is a new IV iron formulation that will be coming on the United States market soon that has the ability to be given as a relatively large dose of over 500 mg in a very fast IV push. This was recently shown in a publication to have a good safety record, although it is a highly selected patient population that excluded patients with previous reactions to IV iron or multiple drug allergies.
In the United States, however, there have been virtually no head-to-head comparisons of different IV preparations, so it's really hard to determine whether any particular IV iron preparation is safer or less safe than others. Although, one of the iron dextrans has been said to be particularly unsafe and, in fact, some have claimed it should be removed from the market, although the data supporting that is still somewhat uncertain.
I would be interested to know what your thoughts about these issues are, particularly your sense of the safety and utility of different IV iron preparations, not only in dialysis patients but in earlier-stage CKD patients. Also, what do you think about the ferritin issue? Is there really a ferritin level above which there is scientific evidence to support limiting additional iron therapy?
I would encourage you to please respond to this blog through the Medscape Website. My name is Jeffrey Berns, from the University of Pennsylvania School of Medicine in Philadelphia.
This feature requires the newest version of Flash. .
This feature requires the newest version of Flash. You can download it here.
Discuss From ASN 2008: Use of IV Iron in CKD Patients
Jeffrey S. Berns, MD: Hello. I'm Jeffrey Berns, Professor of Medicine, Pediatrics, at the University of Pennsylvania School of Medicine in Philadelphia, and Editor-in-Chief of Medscape Nephrology.
I recently chaired a session at the American Society of Nephrology meeting here at Philadelphia on iron, and wanted to comment upon a couple of things that I learned and heard at that meeting.
First, there is clear evidence that IV iron has toxicity, both systemically and in the kidneys. This seems to be mediated by a variety of factors, including inflammatory changes, but there have also been identified changes in DNA and histones and so forth. Clearly, there is potential for significant toxicity -- in experimental animals, though; this hasn't been clearly carried over in humans. I think that still remains uncertain.
There was some discussion about the value of serum ferritin levels, particularly on the high end -- whether these were at all useful in clinical practice. The panelists, as well as members of the audience, raised serious questions as to whether there's any predictive value at all for either efficacy of additional iron or toxicity with serum ferritin levels above 500 or 800 or 1200. Nobody really seems to know what upper limit of ferritin is important for us.
Lastly, there was a fair amount of discussion about different intravenous iron preparations. There is a new IV iron formulation that will be coming on the United States market soon that has the ability to be given as a relatively large dose of over 500 mg in a very fast IV push. This was recently shown in a publication to have a good safety record, although it is a highly selected patient population that excluded patients with previous reactions to IV iron or multiple drug allergies.
In the United States, however, there have been virtually no head-to-head comparisons of different IV preparations, so it's really hard to determine whether any particular IV iron preparation is safer or less safe than others. Although, one of the iron dextrans has been said to be particularly unsafe and, in fact, some have claimed it should be removed from the market, although the data supporting that is still somewhat uncertain.
I would be interested to know what your thoughts about these issues are, particularly your sense of the safety and utility of different IV iron preparations, not only in dialysis patients but in earlier-stage CKD patients. Also, what do you think about the ferritin issue? Is there really a ferritin level above which there is scientific evidence to support limiting additional iron therapy?
I would encourage you to please respond to this blog through the Medscape Website. My name is Jeffrey Berns, from the University of Pennsylvania School of Medicine in Philadelphia.
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