Can iron chelation therapy be used in Chronic Kidney Disease (CKD)?

From the Guidelines

Iron chelation therapy can be used in chronic kidney disease (CKD) patients, particularly those with iron overload conditions, but its use must be carefully considered due to potential nephrotoxicity and the need for dosage adjustments based on kidney function. The primary agents used include deferoxamine, deferasirox, and deferiprone, with dosages ranging from 20-40 mg/kg/day for deferoxamine to 7-28 mg/kg/day for deferasirox and 75-100 mg/kg/day for deferiprone 1. However, the use of these medications in CKD patients requires caution, especially with deferasirox, due to its potential nephrotoxicity 1.

Key Considerations

• Dosage adjustments are necessary based on the patient's kidney function, with lower doses recommended for those with advanced CKD 1.
• Regular monitoring of kidney function, serum ferritin, transferrin saturation, and complete blood counts is essential during treatment 1.
• Iron chelation therapy works by binding to excess iron and facilitating its excretion, primarily through urine or feces, which helps prevent organ damage from iron deposition 1.
• The decision to initiate iron chelation should be made carefully, weighing the benefits of reducing iron overload against the risks of further kidney damage, and should be part of a comprehensive management plan that includes appropriate anemia treatment and kidney disease management 1.

Guideline Recommendations

• The KDIGO guideline on anemia recommends selecting the route of iron administration based on the severity of iron deficiency, availability of venous access, response to prior oral iron therapy, side effects with prior oral or IV iron therapy, patient compliance, and cost 1.
• The guideline also recommends guiding subsequent iron administration in CKD patients based on Hb responses to recent iron therapy, as well as ongoing blood losses, iron status tests, Hb concentration, ESA responsiveness and ESA dose in ESA-treated patients, trends in each parameter, and the patient’s clinical status 1.

From the FDA Drug Label

Deferasirox tablet is contraindicated in patients with eGFR less than 40 mL/min/1.73 m2. Exercise caution in pediatric patients with eGFR between 40 and 60 mL/minute/1.73 m2. If treatment is needed, use the minimum effective dose and monitor renal function frequently. Individualize dose titration based on improvement in renal injury [see Use in Specific Populations (8.6)]. For patients with renal impairment (eGFR 40 to 60 mL/min/1.73 m2) reduce the starting dose by 50%

Iron chelation therapy with deferasirox can be used in patients with Chronic Kidney Disease (CKD) but with caution.

• The drug is contraindicated in patients with eGFR less than 40 mL/min/1.73 m2.
• In patients with eGFR between 40 and 60 mL/minute/1.73 m2, the starting dose should be reduced by 50% and renal function should be monitored frequently.
• Dose titration should be individualized based on improvement in renal injury 2.

From the Research

Iron Chelation Therapy in Chronic Kidney Disease (CKD)

• Iron chelation therapy is not directly mentioned in the provided studies as a treatment option for CKD.
• However, the studies discuss the use of iron supplementation therapy, including oral and intravenous iron, to treat anemia in CKD patients 3, 4, 5, 6, 7.
• The studies suggest that iron supplementation therapy can be effective in improving hemoglobin levels and reducing the need for erythropoiesis-stimulating agents (ESAs) in CKD patients 3, 4, 5, 6.
• However, the safety of intravenous iron therapy is a concern, with potential risks including hypersensitivity reactions, iron overload, and increased risk of infections and cardiovascular events 3, 7.
• The use of low-dose ferrous bisglycinate chelate supplementation has been shown to be effective and well-tolerated in CKD and hemodialysis patients, improving serum iron concentration and transferrin saturation without causing gastrointestinal adverse effects 6.

Key Findings

• Iron supplementation therapy is a critical component of anemia management in CKD patients 4, 5.
• Intravenous iron therapy can be effective in increasing hemoglobin levels and reducing ESA use, but its safety profile is a concern 3, 7.
• Oral iron supplementation is limited by gastrointestinal adverse effects, but new formulations such as ferrous bisglycinate chelate may offer a well-tolerated alternative 6.
• The optimal approach to iron supplementation therapy in CKD patients requires careful consideration of individual patient needs and risks 3, 4, 5, 6, 7.