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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 2  |  Page : 208-211
Use of iron sucrose in dialysis patients sensitive to iron dextran


1 Nephrology Division, King Hussein Medical Center, Amman, Jordan
2 Clinical Pharmacy Department, King Hussein Medical Center, Amman, Jordan
3 Princess Muna College of Nursing, Muta'a University, Amman, Jordan

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   Abstract 

This study aimed to assess the safety and efficacy of iron sucrose in hemodialysis (HD) patients with documented hypersensitivity reactions to iron dextran. Of 205 HD patients who received low molecular weight iron dextran, 15 (7.3%) patients developed documented hypersensitivity reactions. The patients were treated with iron sucrose (100 mg administered as an intravenous push over 5-10 minutes once a week) for 8 weeks. Complete blood count, serum iron, serum ferritin, and parathyroid hormone were measured at the beginning and at the end of the study (except parathyroid hormone). All patients received subcutaneous erythropoietin at a constant dose of 5000 IU twice weekly unless a change was required. All the patients completed the study period and none of them developed hypersensitivity reactions to iron sucrose. The mean hematocrit increased from 23.8% to 32.27% (p < 0.0001), the mean serum ferritin from 185 ng/mL to 599 ng/mL (p < 0.0001), and the mean serum iron from 29.3 ng/dL to 76.8 ng/dL (p = 0.01). We conclude that iron sucrose is safe and effective in HD patients with documented hypersensitivity reactions to low molecular weight iron dextran.

Keywords: Chronic kidney disease, Hemodialysis, Anemia, Iron sucrose, Low molecular weight iron dextran

How to cite this article:
Haddad A, Abbadi R, Marji A. Use of iron sucrose in dialysis patients sensitive to iron dextran. Saudi J Kidney Dis Transpl 2009;20:208-11

How to cite this URL:
Haddad A, Abbadi R, Marji A. Use of iron sucrose in dialysis patients sensitive to iron dextran. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2014 Oct 2];20:208-11. Available from: http://www.sjkdt.org/text.asp?2009/20/2/208/45523

   Introduction Top


Patients with stage 5 chronic kidney disease (CKD) receiving hemodialysis (HD) are prone to iron deficiency for several reasons including reduced iron intake due to a low protein diet, [1],[2] interference with gastrointestinal iron absorp­tion from phosphate binders, [3] and possibly re­duced intestinal iron absorption due to ure­mia. [4] HD may worsen iron deficiency because of bleeding from the access site, blood left in the tubes and dialyzer, and frequent blood tests. [5]

The introduction of recombinant human ery­thropoietin as a therapy for CKD-associated anemia has changed the management of this disorder, but erythropoietin increases the re­quirements for the substrates of erythropoiesis mainly iron in order to be efficacious in most of the cases of anemia in HD.

The administration of oral iron preparations has proven to be inadequate to replenish or maintain iron stores necessary for hematopoie­sis during erythropoietin therapy. [6] Parenteral iron therapy in combination with erythropoie­tin has been shown to be successful and eco­nomic method to treat iron deficiency anemia in patients with CKD. [7] This has resulted in an increased use of iron dextran, [8] however, it carries the risk of variable adverse reactions ranging from mild forms of skin reactions or gastrointestinal disturbances to hypotension, severe bronchospasm, and death. [9]

Another form of parenteral iron is ferric gluconate, sodium ferric gluconate complex in sucrose. It shares many similarities with iron dextran, most importantly anaphylactic reac­tions, but there have been no reported deaths. [10],[11],[12] To minimize reactions to ferric gluconate, the maximum dose is limited to 125 mg in­ fused slowly over one hour. [13],[14]

A third iron preparation is iron sucrose, iron saccharate. Its use in HD patients has been re­ported as safe, well tolerated and effective. [6],[10],[15]

It may be administered in 100 mg doses as an intravenous push over as little as 1 minute and in doses up to 500 mg as a slow intravenous infusion. [16]

We conducted our study in HD patients with proven hypersensitivity reactions to a newly introduced low molecular weight iron dextran by treating them with intravenous iron sucrose to evaluate their response to the latter iron preparation.


   Patients and Methods Top


Our center provides HD therapy to a total of 205 patients with kidney failure, and as a stan­dard measure, all our patients receive erythro­poietin and intravenous iron for the management of anemia. Recently, we started to use low molecular weight iron dextran. A total of 15 (7.3%) patients developed various types of hypersensitivity reactions to the test dose of the low molecular weight iron dextran, ranging from urticaria to mild shortness of breath to hypotension. Those 15 patients were switched to intravenous iron sucrose while maintaining the dose of erythropoietin after a period of two weeks from discontinuing the low molecular weight iron dextran. Patient characteristics are shown in [Table 1].

Iron sucrose was administered in doses of 100 mg via intravenous push over 5-10 minutes during the first hour of the HD session once per week. The erythropoietin dose was con­tinued as subcutaneous injections of 5000 IU twice weekly at the end of the HD session, and the dose was maintained unless required modi­fication.

Patients receiving angiotensin converting en­zyme (ACE) inhibitors at the beginning of the study continued to receive them during the 8 week study period, but these was not added to the treatment regimen of the other patients.

Laboratory data collected at the beginning of the study were complete blood count (CBC), serum iron, serum ferritin and parathyroid hor­mone concentrations. At the end of the study these measurements were repeated except for the parathyroid hormone.

Statistical analysis

Data are presented as the mean. Student's "t" test was used to compare the results and P values less than 0.05 were considered statis­tically significant.


   Results Top


A total of 15 patients who had documented hypersensitivity reactions to test doses of low molecular weight iron dextran received iron sucrose. None of these patients manifested any form of hypersensitivity reactions to iron suc­rose injections, and there were no effects on intradialytic blood pressure.

The initial mean hematocrit was 23.8% and this increased to 32.3% after 8 weeks (p < 0.0001). Of note, 73% of patients achieved a hematocrit of more than 33%, while 80% achieved a hematocrit of more than 30% with the same dose of erythropoietin as used before starting iron sucrose therapy. The mean serum ferritin increased from 185 ng/mL to 599 ng/mL (p < 0.0001) and the mean serum iron also increased from 29.3 ng/dL to 76.7 ng/dL (p = 0.01). [Table 2] summarizes these data.


   Discussion Top


Iron dextran has been the only available pa­renteral iron preparation for a long time. How­ever, its use has been associated with increased risk of allergic reactions, even after reaction­free previous use. [8],[9] Reported reactions to iron dextran include a wide range of symptoms and findings, such as pruritus, palpable purpura, rash, abdominal pain, flank pain, arthralgias, myalgias, fever, hypotension, pulmonary ede­ma, wheezing, stridor, and angioedema. [10] The most severe reactions to iron dextran meet the criteria for anaphylaxis.

The results of our study demonstrate the safety and efficacy of iron sucrose adminis­tration in a group of patients all sensitive to low-molecular weight iron dextran. The intro­duction of iron sucrose for HD patients has been described as safe and effective, even in patients with documented hypersensitivity re­actions to other iron preparations. [10],[15],[16] The North American study by Van Wyck included a less homogeneous group of 22 patients presenting sensitivity to either low- - or high­molcecular-weight dextran. [10]

The rate of allergic reactions to iron dextran varies in the literature. Among our patients we recorded 7.3% rate of hypersensitivity reac­tions to low molecular weight iron dextran.

In our study, there were no reactions to iron sucrose, which is compatible with what has been found in previous studies. [5] The safety of iron sucrose is further confirmed in a large retrospective safety analysis, [17] where this subs­tance is rated with the most advantageous safety profile compared to iron gluconate and iron dextran. However, other studies reported minor hypersensitivity reactions to iron sucrose (Pruritus). [10]

Our patients tolerated intravenous iron suc­rose with significant improvement in their he­matocrit, serum ferritin, and serum iron levels. Moreover, we noticed that the initial levels of serum ferritin did not predict the response to iron sucrose therapy, as all our patients showed significant improvement. Furthermore, we ob­served no effect related to other medications prescribed to the patients, namely, ACE inhi­bitors.

We conclude that iron sucrose is safe and effective in HD patients with documented hypersensitivity reactions to low molecular weight iron dextran.


   Acknowledgment Top


We thank Vifor International and their local representative in Jordan (Al-Kudri drug store) for providing material for the study.

 
   References Top

1.Herbert Herbert V. Recommended dietary intakes (RDI) of iron in humans. Am J Clin Nutr 1987;45:679-86.  Back to cited text no. 1    
2.Bezoda WR, Bothwell TH, Charlton RW, et al. The relative dietary importance of haem and non-haem iron. S Afr Med J 1983;64:552-6.  Back to cited text no. 2    
3.Cannata JB, Gomez-Alonso C, Fernandez­Menendez MJ, et al. Iron uptake in aluminium overload: In vivo and in vitro studies. Nephrol Dial Transplant 1991;6:637-42.  Back to cited text no. 3    
4.Boddy K, Lawson DH, Linton AL, Will G. Iron metabolism in patients with chronic renal failure. Clin Sci 1970;39:115-21.  Back to cited text no. 4  [PUBMED]  
5.Silverberg DS, Blum M, Kaplan E, Iaina A. Intravenous ferric saccharate as an iron supplement in dialysis patients. Nephron 1996;72:413-7.  Back to cited text no. 5  [PUBMED]  
6.Chaytan C, Schwenk MH, Al-Saloum MM, Spnowitz BS. Safety of iron sucrose in HD patients intolerant to other parenteral iron products. Nephron Clin Pract 2004;96:c63-6.  Back to cited text no. 6    
7.Macdougall IC, Tucker B, Thompson J, et al. A randomized controlled study of iron supple­mentation in patients treated with erythro­poietin. Kidney Int 1966;50:1694-99.  Back to cited text no. 7    
8.Hamstra RD, Block NH, Schocket AL. Intravenous iron dextran in clinical medicine. JAMA 1980;243:1726-31.  Back to cited text no. 8    
9.Fishbane S, Ungureanu VD, Maeska JK, et al. The safety of intravenous iron dextran in HD patients. Am J Kidney Dis 1996;28:529-34.  Back to cited text no. 9    
10.Wyck DB, Cavallo G, Spinowitz BS, et al. Safety and efficacy of iron sucrose in patients sensitive to iron dextran: North American Clinical Trial. Am J Kidney Dis 2000;36:88-97.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Fishbane S, Kowalskl EA. The comparative safety of intravenous iron dextran, iron saccharate and sodium ferric gluconate. Semin Dial 2000;13:381-4.  Back to cited text no. 11    
12.Faich G, Strobos J. Sodium ferric gluconate complex in sucrose: Safer intravenous iron therapy than iron dextran. Am J Kidney Dis 1999;33:464-70.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Matzke GR. Intravenous iron supplementation in end stage renal disease. Am J Kidney Dis 1999;33:595-7.  Back to cited text no. 13    
14.Zanen AL, Adriaansen HJ, Van Bommel EJ, et al. Oversaturation of transferrin after intra­venous ferric gluconate in haemodialysis pa­tients. Nephrol Dial Transplant 1996;11: 820-4.  Back to cited text no. 14    
15.Yee J, Besarab A. Iron sucrose: The oldest iron therapy becomes new. Am J Kidney Dis 2002; 40:1111-21.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Chaytan C, Levin N, Al-Saloum M, et al. Efficacy and Safety of iron sucrose for iron deficiency in patients with dialysis-associated anemia: North American Clinical Trial. Am J Kidney Dis 2001;37:300-7.  Back to cited text no. 16    
17.Bailie GR, Clark JA, Lane CE, Lane PL. Hypersensitivity reactions and deaths associated with intravenous iron preparations. Nephrol Dial Transplant 2005;20:1443-9.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Ayham Haddad
Nephrology Division, King Hussein Medical Center, P.O. Box 3808, Amman 1953
Jordan
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PMID: 19237805

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    Tables

  [Table 1], [Table 2]

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Acknowledgment
    References
    Article Tables
 

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