| Abstract|| |
We evaluated in this study the effects of regular use of maintenance intravenous (IV) iron saccharate on the hematological parameters, iron stores, and erythropoietin (EPO) requirement in a group of stable hemodialysis (HD) patients. We maintained 34 stable HD patients (14 (41.2%) males) with a mean age of 43.1 ±16 years (range 17-69) and mean duration of HD of 39.3 ± 34.5 months on EPO. We also added 50-100 mg IV iron saccharate every week during a 6-month period from May-October, 1999. At entry, 18 (47.1%) patients required loading doses of IV iron saccharate. We compared the results at entry with those at six months. The mean hemoglobin increased significantly from 97 ± 10 to 117 ± 20 g/l, (p<0.0001), serum ferritin increased significantly from a mean of 160 ± 224 to 377 ± 216 ng/ml, (p<0.0001), transferrin saturation increased from 21 ±1.9 to 28 ± 8 %, (p= .0002), EPO dose decreased significantly from a mean weekly dose of 8800 ± 3200 to 5500 ± 3000 units (p=0.002). The cost saving analysis suggested an annual savings of 6448 Saudi Riyals (1719 US $) per patient attributable to reduction in the administered EPO dose. We conclude that IV iron saccharate use to replenish and maintain iron stores in stable EPO treated HD patients is safe and effective. It results in achieving target hemoglobin with significantly lower doses of EPO.
Keywords: Renal anemia, Hemodialysis, Iron saccharate, Erythropoietin.
|How to cite this article:|
Al-Mueilo SH. Beneficial Effects of Maintenance Intravenous Iron Saccharate in Hemodialysis Patients. Saudi J Kidney Dis Transpl 2005;16:146-53
|How to cite this URL:|
Al-Mueilo SH. Beneficial Effects of Maintenance Intravenous Iron Saccharate in Hemodialysis Patients. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2020 Aug 11];16:146-53. Available from: http://www.sjkdt.org/text.asp?2005/16/2/146/32933
| Introduction|| |
Anemia is present in the majority of end-stage renal disease (ESRD) patients commencing regular hemodialysis (HD).  Untreated, anemia in renal patients is associated with several functional and structural abnormalities. These include decreased cognitive function,  impaired exercise capacity, defective immune system, , left ventricular hypertrophy, increased cardiac output, angina and congestive heart failure. , Although several factors may be operative in the genesis of renal anemia, insufficient production of erythropoietin (EPO) by the diseased kidneys is by far most significant. ,,
The availability of recombinant human erythropoietin (EPO) in the late 1980's of the last millennium had revolutionized the management of anemia in HD, peritoneal dialysis and pre-dialysis patients. ,, Erythropoietin induced correction of anemia in ESRD patients is associated with several favorable outcomes. Such correction is associated with improved quality of life parameters,  better cognitive function,  relief of some of the uremic symptoms such as pruritus,  improved lipid profile,  and reduced left ventricular mass index and decreased mortality. , Hyporesponsiveness to EPO is occasionally encountered among chronic HD patients and is attributable to several factors, of which absolute and/or functional iron deficiency is the most prevalent.  Absolute iron deficiency in EPO treated HD patients is diagnosed when serum ferritin is less than 100 ng/ml and percentage transferring saturation (TSAT) is less than 20%. Functional iron deficiency refers to the need for a greater amount of iron to support hemoglobin synthesis than can be released from the reticuloendothelial cells and is diagnosed when TSAT is less than 20% in the presence of serum ferritin greater than 100 ng/ml.  Hemodialysis associated iron losses from blood sampling, dialyzer clotting, blood in the dialysis circuit, and post dialysis bleeding are estimated to amount to two grams annually.  In order to sustain EPO induced erythropoiesis and to compensate for these losses, a positive iron balance has to be established. Oral iron therapy is commonly ineffective in this respect. ,, Reasons behind inadequacy of oral iron therapy include in efficient gastrointestinal (GI) absorption, , GI side effects and drugs interactions.  Parenteral iron therapy is the preferred route of administration. ,, Clinical practice is not uniform with respect to type of parenteral iron preparations and dosing strategies. ,,,,,
In this report, we evaluate the effects of regular use of maintenance IV iron saccharate on the hematological parameters, iron store, and EPO requirement in a group of stable HD patients. Additionally, we attempt to analyze the potential cost savings from implementing the study findings.
| Patients and Methods|| |
This is an open-label prospective study on the use of IV iron saccharate (Ferosac®, Spimaco, Saudi Arabia) in adult HD patients that we performed at King Fahd Hospital of the University (KFHU), Alkhobar, Saudi Arabia from May-October, 1999. The patients included in the study are end-stage renal disease patients who had been on regular maintenance hemodialysis and on subcutaneous EPO (Eprex®, pre-filled syringes, Cilag AG international 6300 Zug, Switzerland) for at least six months.
None of the patients had received IV iron prior to enrollment. The majority of the patients were on oral iron. Patients with active infection, inflammation or gastrointestinal bleeding were excluded. At time of entry to the study and once a month thereafter, hemoglobin (Hgb), hematocrit (Hct) and TSAT were obtained. Serum B12 level, serum folate and RBC folate were determined at baseline.
The average weekly dose of EPO before enrollment into the trial and for every month thereafter was determined from patients' records. Efficiency of dialysis was estimated by calculating the urea reduction ratio (URR) at baseline and every month.
At onset of the study, we stopped the oral iron therapy and initiated IV iron saccharate protocol and monitored the status of the iron stores. If serum ferritin was > 100 ng/ml and TSAT > 20%, a weekly dose of 50-100 mg iron saccharate infused intravenously over 10 minutes in the venous limb of the vascular access after dialysis was commenced. On the other hand, if the patient was iron deficient as defined by serum ferritin < 100 ng/ml and/ or TSAT < 20%, a loading cumulative dose of 500-1200 mg iron saccharate divided to 100 mg doses post dialysis. This was followed by a maintenance dose of 50-100 mg IV post dialysis once/week. Iron saccharate was held whenever serum ferritin exceeded 800 ng/ml and resumed when the serum level decreased below 600 ng/ml. EPO was administered subcutaneously after dialysis 1-3 times/week. The pretrial EPO dose was kept the same during the first month of IV iron therapy. The level of Hgb/Hct guided further adjustment of EPO dose. When Hgb exceeds 12 gm/dl, the EPO dose was reduced by 25%. If Hct increased less than 2% over 2-4 weeks, the EPO dose was increased by 25%. The effects of iron therapy were monitored by changes in Hgb, Hct, serum ferritin level, TSAT and average weekly EPO dose every month during the six months of the study.
A cost saving analysis was performed based on the acquisition cost for EPO and iron saccharate by (KFHU) in Saudi Riyal (SR), (exchange rate is 1 US$ = 3.75 SR). The cost of erythropoietin was 160 SR (42.7 US$) for each 4000 prefilled syringe. The acquisition cost of iron saccharate is estimated at 15 SR (4 US$) per 100 mg ampoule. Changes in EPO cost were estimated based on the difference in dose at the start and end of the study. The cost of iron saccharate was subtracted from any potential savings from changes in EPO dosing. The cost associated with overhead, physician and nurse time were not included in the analysis.
| Statistical Analysis|| |
Data are represented as mean ± SD. Each patient was used as his/her own prospective control. Hgb, Hct, serum ferritin, TSAT, weekly EPO dose and URR were analyzed with Student's paired t-test to compare the pretrial values with values at 3 and 6 months. Probability (p) value < 0.05 was considered as statistically significant.
| Results|| |
Thirty-four patients with ESRD on HD were enrolled in the study. There were 14 males (41.2%); mean age of the whole group was 43.1 ± 16 years (range 17-69). All patients were on bicarbonate mode of HD for 3-4 hours, 3 sessions / week. All patients were receiving EPO subcutaneously, with an average weekly dose of 8800 ± 3200 units. The average duration of HD before entering the study was 39.3 ± 34.5 months (range 6-118). Twenty-eight (82.4%) patients were on oral iron therapy, which was stopped at the start of the study. None of the patients had evidence of B12 or folate deficiency at time of entry.
At entry 18 (47.1%) patients received loading doses of 500-1200 mg iron saccharate given as IV infusion over 10 minutes after dialysis in divided doses of 100 mg each session after an initial test IV dose of 25 mg; one of these patients subsequently required a second loading dose of 500mg. this was followed by weekly supplemental IV iron saccharate of 50-100 mg. The remainder of the patients received the maintenance dose since the start of the study. At 6 months, 32 patients were receiving 50 mg/week and two patients were on 100mg/ week.
We compared the results at entry with those at six months. The mean hemoglobin increased significantly from 97 ± 10 to 117 ± 20 g/l, (p<0.0001), serum ferritin increased significantly from a mean of 160 ± 224 to 377 ± 216 ng/ml, (p<0.0001), transferrin saturation increased from 21 ±1.9 to 28 ± 8 %, (p= .0002). In fact, the changes in these parameters were already evident at three months from initiation of the IV iron saccharate therapy, [Table - 1].
At the time of entry 18 patients (53%) had serum ferritin <100 ng/ml, and 20 patients (58.8%) had TSAT < 20%. By the end of 6 months these had decreased to three patients (8.8%) and six patients (17.6%), respectively.
Concomitant with these favorable changes, the administered EPO dose decreased significantly from a mean weekly dose of 8800 ± 3200 units at entry to 7800 ± 3400 units at three months, (p=0.02) and 5500 ± 3000 units at 6 months, (p=0.002). The efficiency of hemodialysis treatments as judged by the URR had not significantly changed during the study period.
The mean iron saccharate consumed dose was 144, 69 and 54.4 mg /patient /week at one, three and six months of therapy. No adverse reactions attributable to iron saccharate infusions were observed in any of the patients. There was no noted increase in the incidence of infectious episodes among the patients during the study period.
In the first month of the study, there was a 6.1% increase in the cost due to the loading doses of iron saccharate used to optimize iron stores. However, the significant reduction in the required EPO dose quickly negated this added cost. At six months of the study, there was a 35% decrease in the cost associated with EPO use, when compared to the cost prior to the study. The savings at the end of the study was calculated to be 124 SR / patient /week and the projected annual saving would be 6448 SR per patient (1719 US$ per patient).
In a subgroup of nine patients (three males and six females with a mean age of 40.2 ± 18 years and mean duration on HD of 34.8 ± 37.8 months) who were iron replete as defined by serum ferritin and TSAT greater than 100 ng/ml and 20% respectively, the intravenous weekly maintenance iron saccharates resulted in an increase in serum ferritin from 185.8 ± 80.7 at baseline to 445.1 ± 177.9 ng/ml at 6 months (p= 0.001). Mean hemoglobin increased from 10.1 ± 1.3 at base-line to 11.6 ± 1.9 gm/dl at 6 months. Over the same period mean administered EPO dose decreased from 7900 ± 3500 to 7000 ± 3900 units/ patient/ week; a decrease of 11.2%. However the changes in Hgb and mean EPO dose were not statistically significant.
| Discussion|| |
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines have recommended target Hgb (Hct) of 11g/dl (33%) to Hgb 12 g/dl (36%) in most EPO treated HD patients.  This recommendation is based on the noted decreased quality of life and increased morbidity and mortality in chronic kidney disease patients as Hgb/Hct falls below 10 (33%). ,,,, Since oral iron supplementation is usually insufficient to reach these targets, parenteral iron is necessary in HD patients treated with EPO. ,,
Iron dextran has been associated with serious side effects such as anaphylactoid reactions and even death in rare instances.  The wider availability of other IV iron preparations such as iron gluconate and iron saccharate (sucrose) has simplified iron management in HD patients with a better safety profile than iron dextran. ,,,,
The recent introduction of heme-iron polypeptides (HIP) is promising. These oral iron preparations are absorbed to a greater extent, and are better tolerated. Use of HIP in EPO treated HD patients during a 6-month open prospective trial maintained target Hgb without the need for concomitant use of IV iron.  However, 4 of 37 (11%) patients in this trial dropped out because of side effects or insufficient iron supplementation. Wider acceptance of these compounds in clinical practice awaits confirmation of safety and efficacy from larger and longer clinical trials.
Our study demonstrates that adopting an IV iron saccharate protocol in HD patients is safe, effective and economically cost effective. Significant increase in the Hgb, Hct, ferritin, and TSAT was observed at the end of the study coupled with a remarkable reduction in the administered EPO dose.
Several investigators had reported similar benefits. ,,,, Park et al  treated 30 iron deficient HD patients on EPO with IV loading dose of 1gm iron dextran in five divided doses followed by a monthly dose of 100 mg during a 4-month study period. At the end of the 4month study, mean serum ferritin and TSAT had increased significantly from 49 ng/ml to 225 ng/ml and 27% to 33%, respectively. Values for hemoglobin did not change significantly during the study period; however, there was a significant reduction in EPO dose from a mean baseline dose of 112 U/kg/wk to 88 U/kg/wk at the end of the study. The authors' economic analysis suggested that approximately 580 Canadian $/ patient/ year could be saved by use of IV iron dextran. Furthermore, Macdougall et al  administered a weekly IV bolus of 100 mg iron sucrose to 116 HD patients with low serum ferritin. At 12 months, mean serum ferritin and hemoglobin level significantly increased from 214 ng/ml to 564 ng/ml and from 9.6 g/dl to 10.7 g/dl, respectively. Over the same period, there was a dramatic 32.4 % reduction in mean EPO dose. This resulted in cost savings of approximately 244 US$/ patient/ month.
Intravenous maintenance iron therapy may be worthwhile even in iron replete EPO treated HD patients. Chang CH et al  conducted a 12-month intravenous iron substitution trial in 149 iron-replete chronic HD patients (mean serum ferritin 930 ± 857 ng/ml) receiving subcutaneous EPO therapy. The available iron pool was maintained with 100 mg iron every 2 weeks or 1 month depending on serum ferritin and TSAT levels. After 12 months, the mean Hct increased significantly from 27.7 to 28.7 %. The mean serum ferritin and TSAT also increased significantly. EPO requirement could be reduced by 25%. The estimated cost saving on EPO administration was around 400US$ / patient/ year.
We had similar findings in our patients who were iron replete as defined by serum ferritin and TSAT greater than 100 ng/ml and 20% respectively. However, due to the small size sample, changes in Hgb and mean EPO dose were not statistically significant.
Finally, there is theoretical potential risk of iron maintenance therapy such as risk of infection and atherosclerotic cardiovascular disease. However, clinical studies so far do not show such increased risk. ,, The benefits of intravenous iron therapy outweigh the potential risks in most HD patients. However, careful monitoring is essential to ensure safety and success of IV iron policy in HD patients.
In conclusion, the use of intravenous iron saccharate to replenish and maintain iron stores in stable EPO treated HD patients is safe and effective. It results in achieving target Hgb with significantly lower doses of EPO. There fore, significant EPO related cost saving can be accomplished by implementation of IV iron therapy protocol.
| Acknowledgement|| |
We wish to thank Prof. Fahd Al-Muhanna and Dr. Ibrahim Saeed for their help and support in carrying out the study. I also thank Mrs. Ezdehar Barbari, Mrs. Daisy Donesa and the nursing staff at KFHU hemodialysis unit for their assistance in implementing the protocol and data collection.
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Samir H Al-Mueilo
Department of Nephrology, King Fahd Hospital of the University, P.O. Box 40154, Alkhobar 31952
[Table - 1]