Anemia and iron target realization in 1998: Clinical management of anemia in 1,639 patients on hemodialysis

Anemia management in hemodialysis patients continues to evolve, and recentl y, greater emphasis has been placed on the wider use of intravenous iron to maintain adequate iron levels. This survey provides scarcely available yet potentially useful information on the clinical treatment of anemia in a la rge cohort of hemodialysis patients. The erythropoietin and iron administra tion details and pertinent laboratory measurements from 1,639 patients were analyzed for the month of December, 1998. A standardized protocol had been used in that erythropoietin was begun at a total weekly dose of 150 U/kg I V or 100 U/kg subcutaneously and was then adjusted to maintain a hematocrit (Hct) of 33-36%. Iron supplements, oral, IV, or both, were administered to maintain percent transferrin saturation (TSAT) at 20-30% and/or a serum fe rritin of 100-500 ng/ml. No intravenous iron was administered if the ferrit in was more than 500 ng/ml. Although 82% of patients were on iron supplemen tation and, among them, 58% were on IV iron, the percentage of patients wit h TSAT >20, i.e., bioavailable iron, was only 51%. The serum ferritin was h igh at 498 +/- 10 ng/ml (mean SEM) and 88% and 10% of patients had serum fe rritin >100 and >1,000 ng/ml, respectively, suggestive of sequestration of part of the infused iron. Erythropoietin was administered to 96% of patient s, 99.5% by IV route. The latter was consistent with the US dialysis popula tion at large but in variance with DOQI preference for the subcutaneous rou te. The target Hct range of 33-36 was found in 33%, with a mean Hct of 34.0 +/- 0.12. When the data were reanalyzed by excluding patients who had not been receiving erythropoietin and had not been on dialysis for at least 3 m onths, the percentage of patients achieving the target Hct increased to 37% . Paired analysis of 875 patients present in 1996 and 1998 showed that, alt hough there was a marked increase in the use of IV iron, the improvement in anemia was modest, and there was evidence for increased iron accumulation. In summary, this 1998 survey on the clinical practice of anemia management in a large hemodialysis population indicates that there is a marked increa se in need-based IV iron usage that was associated with modest improvement in anemia and evidence for increased iron storage. A maintenance iron dosin g protocol with smaller doses of iron, such as 25 mg of iron dextran per he modialysis, may make bioavailable iron continuously present for erythropoie sis, yet may reduce the chance for iron catalyzed lipid peroxidation and ti ssue iron deposition.