Intravenous Versus Oral Iron for Treatment of Iron Deficiency in Non-hemodialysis-dependent Patients With Chronic Kidney Disease

Anne Marie Liles

Disclosures

Am J Health Syst Pharm. 2012;69(14):1206-1211. 

In This Article

Background

The National Kidney Foundation's (NKF's) Kidney Disease Outcomes and Quality Initiative (KDOQI) recommends the use of i.v. iron in patients receiving hemodialysis, but NKF has not issued a guideline for the type of iron supplementation to use in ND-CKD patients.[1] Guidelines issued by the European Renal Association and European Dialysis and Transplant Association recommend i.v. iron for patients with CKD, regardless of the use of hemodialysis, due to the poor absorption of oral iron in these patients.[6] Evidence demonstrates the superiority of i.v. iron in hemodialysis patients.[7,8] In contrast, evidence evaluating the efficacy of i.v. versus oral iron in ND-CKD patients is unclear. Both dosage forms have disadvantages that may influence the health care practitioner's choice of iron. Oral iron has been associated with adverse gastrointestinal effects and may require the administration of multiple doses daily.[3] Absorption of oral iron may also be limited by decreased gastrointestinal absorption due to the inflammation associated with CKD. This inflammation increases the production of hepcidin, a protein produced in the liver that regulates iron homeostasis, thereby inhibiting the absorption of iron from the intestine and inhibiting iron release from macrophages and hepatocytes.[9] The use of i.v. iron is more costly than oral iron when accounting for drug cost, administration costs, and indirect costs to the patient for time and travel and can cause rare but serious short-term effects including anaphylactic-type reactions, hypotension, and arthralgia. The frequency of these reactions varies among i.v. iron products and is highest with high-molecular-weight products, which have also been associated with long-term effects such as infection, atherosclerosis, endothelial dysfunction, and renal injury (transient pro-teinuria and tubular damage).[10]

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