What is the treatment for a 61-year-old male patient with End-Stage Renal Disease (ESRD), anemia, low iron level, normal Mean Corpuscular Volume (MCV), and high ferritin level?

Treatment of Anemia in ESRD Patient with Low Iron, Normal MCV, and High Ferritin

Intravenous (IV) iron is the most appropriate treatment for this 61-year-old male ESRD patient with anemia characterized by low hemoglobin, low iron, normal MCV, and high ferritin.

Understanding the Patient's Iron Status

This patient presents with a classic pattern of functional iron deficiency in the setting of ESRD:

• Low hemoglobin indicates anemia
• Low iron level suggests iron deficiency
• Normal MCV (not microcytic) is common in renal anemia
• High ferritin reflects inflammation in ESRD rather than adequate iron stores

Pathophysiology

In ESRD patients, several factors contribute to this pattern:

• Chronic inflammation increases hepcidin, blocking iron release from stores
• Blood losses during hemodialysis procedures
• Reduced intestinal iron absorption
• Functional iron deficiency (inadequate iron availability despite normal or high stores)

Treatment Decision Algorithm

1. First-line treatment: IV iron 1, 2

   • IV iron bypasses the absorption issues of oral iron
   • Effectively delivers iron directly to the bone marrow
   • Overcomes functional iron deficiency by saturating transferrin

2. Second-line treatment: Erythropoietin (ESA) 2, 1

   • Should be added after or concurrently with IV iron
   • Iron repletion improves ESA responsiveness
   • Target hemoglobin of 11-12 g/dL

3. Not recommended as first-line:

   • Oral iron (poor absorption in ESRD) 1
   • Blood transfusion (reserved for severe symptomatic anemia)

Evidence Supporting IV Iron

The National Kidney Foundation KDOQI guidelines recommend IV iron for ESRD patients with:

• TSAT < 20% and ferritin < 200 ng/mL for hemodialysis patients 2, 1
• Even with higher ferritin levels (up to 500 ng/mL), IV iron can be beneficial if TSAT is low 2

Clinical studies demonstrate that IV iron:

• Increases hemoglobin more effectively than oral iron 3
• Reduces ESA dose requirements 1
• Improves quality of life and reduces mortality 1

Dosing and Administration

• Initial dosing: 100-125 mg IV at each hemodialysis session for 8-10 doses 1
• Alternative approach: 500-1000 mg as a single infusion, repeated as needed 1
• Iron sucrose (Venofer) has shown efficacy in multiple clinical trials with ESRD patients 3

Monitoring

• Check TSAT and ferritin every 3 months during maintenance therapy 1
• Monitor hemoglobin at least monthly until stable 1
• Target parameters: TSAT > 20% and ferritin > 200 ng/mL for hemodialysis patients 1

Important Considerations

• High ferritin in ESRD often reflects inflammation rather than iron overload 2, 1
• Withhold IV iron during active infections 1
• The PIVOTAL trial showed that proactive IV iron administration (unless ferritin >700 ng/mL or TSAT >40%) was superior to a reactive strategy 2
• Excessive IV iron may potentially increase oxidative stress and cardiovascular events, so regular monitoring is essential 2

Answer to Multiple Choice Question

The correct answer is C. IV iron.