Optimal IV iron dosing to manage anemia in hemodialysis patients

Almost all patients on hemodialysis experience anemia, a deficiency of red blood cells causing fatigue and weakness. For over two decades, nephrologists have treated anemia in hemodialysis patients with erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron. However, there is currently no consensus on the optimal IV iron dose to raise or sustain hemoglobin at appropriate levels, without very high ferritin or TSAT levels and without excessive use of ESAs.


To help determine this optimal IV iron dose, investigators examined data from nearly 10,000 patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) from 11 countries between 2009 and 2011. Of these patients,

  • Thirty percent received no IV iron
  • Forty percent received (on average) less than 300 mg of IV iron per month (typically 100-200 mg per month)
  • Thirty percent received 300 mg or more of IV iron per month

Researchers found that over a three-month period, levels of hemoglobin, ferritin, and TSAT remained stable most often in the middle group of patients receiving less than 300 mg of IV iron per month. This middle dose group also saw consistent relative decreases in ESA dose over this period, limiting the need to adjust ESA dose in everyday dialysis practice. The group that received higher IV iron doses of 300 mg or more per month was associated with lower doses of ESAs, but at the cost of greater rise in ferritin and/or TSAT, even when already at high levels.

“These findings are yet more important when placed in the context that existing studies have, to our knowledge, found elevated clinical risk only at IV iron doses above 300 mg per month. Thus, IV iron doses of less than 300 mg per month are not only effective, but also appear to be safe,” added lead author Dr. Bruce M. Robinson.

These findings suggest that, for most patients, IV iron dosing of less than 300 mg per month is sufficient to achieve and maintain hemoglobin levels in target range and to limit unnecessarily high ESA dose. This approach stands in contrast to the higher IV iron doses often given in many European and North American hemodialysis clinics.

CITATION:Robinson BM, Larkina M, Bieber B, Kleophas W, Li Y, Locatelli F, McCullough K, Nolen JG, Port FK, Pisoni RL. Evaluating the effectiveness of IV iron dosing for anemia management in common clinical practice: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). BMC Nephrol. 2017 Nov 9;18(1):330. doi: 10.1186/s12882-017-0745-9.
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