Clinical Kidney Journal, Volume 10, Suppl 1, 1 December 2017
A group of experts have come together for a special edition of the ERA-EDTA journal to review recent developments in iron therapy for patients with chronic kidney disease (CKD), as well as to provide practical considerations for anaemia management.
In his introduction to the supplement Professor Iain Macdougall (UK) outlines the high prevalence of iron deficiency in CKD patients, particularly those on dialysis. As the role of iron extends beyond maintaining haemoglobin levels to encompass a broad range of physiological processes, iron deficiency can have widespread consequences, and in CKD patients is associated with lower quality of life and worse outcomes.
Intravenous (IV) iron therapy is used widely, particularly in haemodialysis patients, and its use is supported by multiple clinical guidelines.1,2,3 However, there remains some uncertainty regarding the use of IV iron, fuelled, in part, by conflicting study results. The articles in this CKJ supplement aim to clarify the recommended use of IV iron according to recent guidelines, provide analysis of recent studies, and assess the possible implications for CKD patients of studies of IV iron therapy in patients with iron deficiency and heart failure.
Summary of articles in CKJ supplement
Special issue: iron therapy in patients with chronic kidney disease. Iain C Macdougall (UK)
- Professor Macdougall introduces the importance of iron therapy and the ongoing concerns which this supplement aims to address.4
- When the 2012 KDIGO Guidelines were originally being developed, data on the use of iron therapy in CKD were still emerging, and the quality of evidence used for the recommendations was rated as low or very low. Here, Dr Berns discusses how to interpret the Guidelines in light of recent research, particularly regarding intravenous iron therapy.
- Concluding his article, Dr Berns acknowledges the need for longer-term safety data for IV iron as well as improved biomarkers to assess iron deficiency and guide treatment decisions.5
- While guidelines provide general recommendations for the use of iron therapy in CKD, it is up to the physician to translate them into the practical care of individual patients, also taking into account new research and local regulatory and budgetary constraints. In this article, Dr Simon Roger covers implementation of the KDIGO Guidelines focused on the key clinical decisions facing nephrologists and provides case studies as examples.
- Emphasising the need for individual patient assessment, Dr Roger concludes that IV iron may become the preferred treatment option for non-dialysis patients who need to increase haemoglobin or delay initiation of alternative anaemia therapies.6
- New data has been published which influences the application of the KDIGO Guidelines and use of iron therapy. This article takes an in-depth look at two of the most relevant trials, FIND-CKD and REVOKE, and summarises the results of important observational studies.
- Inconsistencies between trial designs, iron therapy used and event reporting make it difficult to draw firm conclusions. Professor Macdougall concludes that the remaining evidence gap may be filled by the PIVOTAL trial, results of which will become available in 2018.7
Iron therapy in heart failure patients without anaemia: possible implications for chronic kidney disease patients. Jolanta Malyszko (Poland) and Stefan D Anker (Germany)
- While the need to correct iron deficiency anaemia is well-established, the benefits of treating iron deficiency without overt anaemia are less well understood. As heart failure and kidney disease are often comorbid (the cardio-renal patient), this article looks at studies of intravenous iron therapy in iron-deficient heart failure patients with or without anaemia, and how the results may influence decision making in the CKD patient.
- The studies show that treating iron deficiency with IV iron is beneficial, independent of haemoglobin levels, in heart failure patients. The authors conclude that the next step is studying the effects of IV iron in iron-deficient, non-anaemic CKD patients.8
- KDIGO Anemia Working Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int. 2012;2(4):279-335.
- Kliger AS, Foley RN, Goldfarb DS, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for anemia in CKD. Am J Kidney Dis. 2013;62(5):849-859. doi:10.1053/j.ajkd.2013.06.008.
- Locatelli F, Covic A, Eckardt KU, Wiecek A, Vanholder R. Anaemia management in patients with chronic kidney disease: A position statement by the Anaemia Working Group of European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2009;24(2):348-354. doi:10.1093/ndt/gfn653.
- Macdougall IC. Special issue: iron therapy in patients with chronic kidney disease. Clin Kidney J. 2017;10(suppl_1):i1-i2. doi:10.1093/ckj/sfx043.
- Berns JS. Interpretation of the Kidney Disease: Improving Global Outcomes guidelines for iron therapy: commentary and emerging evidence. Clin Kidney J. 2017;10(suppl_1):i3-i8. doi:10.1093/ckj/sfx042.
- Roger SD. Practical considerations for iron therapy in the management of anaemia in patients with chronic kidney disease. Clin Kidney J. 2017;10(suppl_1):i9-i15. doi:10.1093/ckj/sfx100.
- Macdougall IC. Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions. Clin Kidney J. 2017;10(suppl_1):i16-i24. doi:10.1093/ckj/sfx043.
- Malyszko J, Anker SD. Iron therapy in heart failure patients without anaemia: possible implications for chronic kidney disease patients. Clin Kidney J. 2017;10(suppl_1):i25-i31. doi:10.1093/ckj/sfx070.