Date of publication: July 10, 2018

Medical Education

Module 4: Assessing and Correcting the Negative Iron Balance Associated with CKD

In the absence of underlying disease, iron content in the human body is regulated as a virtually closed system – with very little iron being lost and a commensurate amount being absorbed.(1) In patients with chronic kidney disease (CKD), iron losses are often increased and exceed absorbed iron. This results in a negative iron balance which can progress to absolute iron deficiency.(2) Iron therapy aims to replace lost iron stores, prevent iron deficiency, and increase iron available for erythropoiesis.(3,4) Understanding how oral and intravenous iron administration influences iron balance provides the basis for the appropriate use of these medications in clinical practice.

This e-learning module was developed with scientific input and guidance from Professor Jay B. Wish (Medical Director of the Out-Patient Dialysis Unit at Indiana University Hospital and Professor of Clinical Medicine at Indiana University School of Medicine in Indianapolis, Indiana, USA) and Professor Lawrence McMahon (Director of the Department of Renal Medicine and Obstetric Medicine at Eastern Health, and Professor of Nephrology at Monash University, Melbourne, Australia). The module is available in a user-friendly slide format with referenced slide notes, animations, and hyperlinks. The module is divided into 2 distinct chapters to enable you to learn at your own pace and gain maximum benefit from the information presented.

Chapter 1 reviews normal iron regulation and introduces the concept iron balance before exploring the negative iron balance experienced by many with CKD. It goes on to describe the relationship between negative iron balance and renal anaemia and examine current recommendations surrounding the use of iron therapy in the CKD population. Chapter 2 explores the differences between positive iron balance and iron toxicity. This chapter also reviews the physiologic mechanisms and clinical trial data supporting the use of intravenous iron to correct the negative iron balance associated with CKD.


  1. Hotz K, Krayenbuehl PA, Walczyk T. Mobilization of storage iron is reflected in the iron isotopic composition of blood in humans. J Biol Inorg Chem 2012;17(2):301-309.
  2. Wish JB, Aronoff GR, Bacon BR, et al. Positive iron balance in chronic kidney disease: How much is too much and how to tell? Am J Nephrol 2018;47(2):72-83.
  3. Macdougall IC, Bircher AJ, Eckardt KU, et al. Iron management in chronic kidney disease: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int 2016;89(1):28-39.
  4. KDIGO Clinical Practice Guideline for Anaemia in Chronic Kidney Disease. Kidney Int Suppl 2012;2:283–287.

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