Should a patient with End-Stage Renal Disease (ESRD) and severe anemia be given an iron infusion?

Iron Infusion for ESRD Patient with Hemoglobin 7.4 g/dL

Yes, you should give iron infusion to this ESRD patient with severe anemia (Hgb 7.4 g/dL), but only after checking iron parameters (transferrin saturation and ferritin) to confirm iron deficiency and ruling out other causes of severe anemia. 1

Critical First Steps Before Iron Administration

Check iron parameters immediately: 1

• Measure transferrin saturation (TSAT) and serum ferritin
• If TSAT <20% and/or ferritin <100 ng/mL in hemodialysis patients, iron deficiency is confirmed 1
• If TSAT <20% and/or ferritin <200 ng/mL in peritoneal dialysis patients, iron deficiency is confirmed 2

Rule out other causes of severe anemia at this hemoglobin level: 1

• Complete blood count with differential and platelet count
• Absolute reticulocyte count
• Vitamin B12 and folate levels
• Consider acute blood loss, hemolysis, or other pathology given the severity

Iron Administration Protocol for Confirmed Iron Deficiency

For hemodialysis patients with TSAT <20% and/or ferritin <100 ng/mL: 1, 3

• Administer 100-125 mg IV iron at each hemodialysis session for 8-10 consecutive doses
• This provides rapid iron repletion for severe anemia
• Most hemodialysis patients require intravenous iron on a regular basis to maintain adequate stores 1

Alternative dosing regimen: 1

• 500-1,000 mg iron dextran IV in a single infusion after a 25 mg test dose
• Repeat as needed based on iron parameters

For peritoneal dialysis patients: 4

• 300 mg IV on Day 1 and Day 15, then 400 mg on Day 29
• Oral iron is unlikely to maintain adequate iron status in dialysis patients 1

Critical Safety Considerations

Do NOT give iron if: 1, 3

• TSAT >50% and/or ferritin >800 ng/mL (withhold for up to 3 months)
• Active infection is present (defer until infection resolves) 5
• Patient has signs of iron overload

Monitor for adverse reactions during infusion: 4

• Hypotension, flushing, abdominal cramps
• Anaphylactoid reactions (rare but possible)

Concurrent ESA Therapy Consideration

At hemoglobin 7.4 g/dL, this patient likely needs both iron AND erythropoiesis-stimulating agent (ESA): 1

• Supplemental iron should be administered to maintain adequate iron stores in conjunction with Epoetin therapy 1
• Target hemoglobin is 10-12 g/dL (avoid exceeding 12 g/dL due to increased mortality risk) 1
• Iron deficiency is the most common cause of ESA hyporesponsiveness 5, 2

However, consider iron trial first if: 1

• Patient has cardiovascular risk factors (stroke history, active malignancy)
• KDIGO guidelines suggest considering iron therapy response before initiating ESA in some cases 1

Monitoring After Iron Administration

Reassess iron parameters: 1, 3

• Wait 2 weeks after doses ≥1,000 mg before checking iron studies 1
• Wait 7+ days after 200-500 mg doses 1
• Doses ≤125 mg weekly do not require interruption for accurate measurements 1

Monitor hemoglobin response: 4

• Expect hemoglobin increase of 1-2 g/dL within 2-4 weeks if iron deficiency was the primary issue 4
• If inadequate response, investigate other causes of anemia 1

Common Pitfalls to Avoid

Do not assume oral iron is adequate: 1, 3

• Hemodialysis patients almost universally require IV iron supplementation 3
• Oral iron is unlikely to maintain TSAT >20% and ferritin >100 ng/mL in dialysis patients 1

Do not rely solely on ferritin during acute illness: 3

• Ferritin is an acute-phase reactant and may be falsely elevated during inflammation or infection 3
• Use TSAT in conjunction with ferritin for accurate assessment 1

Do not delay transfusion if symptomatic: 1

• At Hgb 7.4 g/dL with severe anemia-related symptoms, RBC transfusion may be needed immediately while addressing iron deficiency 1