The Comparative Short-term Effectiveness of Iron Dosing and Formulations in US Hemodialysis Patients - 18/05/13

Doi : 10.1016/j.amjmed.2012.11.030

Abhijit V. Kshirsagar, MD, MPH ^a,^⁎ , Janet K. Freburger, PhD ^b, Alan R. Ellis, PhD ^b, Lily Wang, PhD ^b, Wolfgang C. Winkelmayer, MD, ScD ^c, M. Alan Brookhart, PhD ^b,^d
^a University of North Carolina Kidney Center, UNC School of Medicine, Chapel Hill
^b Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
^c Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif
^d Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill

Requests for reprints should be addressed to Abhijit V. Kshirsagar, MD, MPH, CB 7155 7017 Burnett-Womack Hall, Chapel Hill, NC 27599-7155.

Abstract

Background

Intravenous iron is used widely in hemodialysis, yet there are limited data on the effectiveness of contemporary dosing strategies or formulation type.

Methods

We conducted a retrospective cohort study using data from the clinical database of a large dialysis provider (years 2004-2008) merged with administrative data from the US Renal Data System to compare the effects of intravenous iron use on anemia management. Dosing comparisons were bolus (consecutive doses ≥100 mg exceeding 600 mg during 1 month) versus maintenance (all other iron doses during the month); and high (>200 mg over 1 month) versus low dose (≤200 mg over 1 month). Formulation comparison was administration of ferric gluconate versus iron sucrose over 1 month. Outcomes were hemoglobin, epoetin dose, transferrin saturation, and serum ferritin during 6 weeks of follow-up.

Results

We identified 117,050 patients for the dosing comparison, and 66,207 patients for the formulation comparison. Bolus dosing was associated with higher average adjusted hemoglobin (+0.23 g/dL; 95% confidence interval [CI], 0.21-0.26), transferrin saturation (+3.31%; 95% CI, 2.99-3.63), serum ferritin (+151 μg/L; 95% CI, 134.9-168.7), and lower average epoetin dose (−464 units; 95% CI, −583 to −343) compared with maintenance. Similar trends were observed with high-dose iron versus low-dose. Iron sucrose was associated with higher adjusted average hemoglobin (+0.16 g/dL; 95% CI, 0.12-0.19) versus ferric gluconate.

Conclusions

Strategies favoring large doses of intravenous iron or iron sucrose lead to improved measures of anemia management. These potential benefits should be weighed against risks, which currently remain incompletely characterized.

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Keywords : Anemia, Hemodialysis, Intravenous iron

Esquema

Methods

Data Sources

Study Design

Cohort Identification

	Funding: This project was funded under Contract No. HHSA290200500401 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (DHHS) as part of the Developing Evidence to Inform Decisions about Effectiveness (DECIDE) program.
	Conflict of Interest: MAB: investigator-initiated support from Amgen, and advisory boards for Amgen, Pfizer, and Rockwell Medical. WCW: scientific advisory board for Amgen and Fibrogen. JKF: investigator initiated support from Amgen.
	Authorship: All authors had access to the data and a role in writing the manuscript.