Is iron sucrose (iron sucrose) 100mg every hemodialysis session for 10 doses, then every 2 weeks, an appropriate treatment for a patient with low Transferrin Saturation (TSAT) of 10% and when should Complete Blood Counts (CBC) and iron studies be repeated?

Iron Sucrose Dosing for TSAT 10% in Hemodialysis

Your proposed regimen of iron sucrose 100mg every hemodialysis session for 10 doses, then every 2 weeks, is appropriate for initial repletion but requires modification for maintenance dosing based on iron parameters. 1, 2, 3

Initial Loading Phase (First 10 Doses)

• Administer iron sucrose 100mg undiluted as slow IV push over 2-5 minutes during each hemodialysis session for 10 consecutive sessions, delivering a total of 1000mg over 8-10 weeks 1, 3, 4
• This loading regimen is specifically designed for hemodialysis patients with severe iron deficiency (TSAT 10% is well below the target of ≥20%) 1, 2
• The 100mg dose per session is safe and does not require a test dose 3, 4, 5

Critical Monitoring Timeline

Do NOT check iron studies immediately after completing the loading phase. The most common pitfall is checking labs too early, which yields falsely elevated results. 2

• Wait 7 days after the 10th (final) dose before checking TSAT, ferritin, and CBC 2
• During the loading phase itself, if the patient is receiving regular IV iron, check TSAT and ferritin at least every 3 months (not more frequently unless clinically indicated) 1
• Check CBC monthly during the loading phase to assess hemoglobin response 1

Maintenance Phase Decision Algorithm

After completing 10 doses and waiting 7 days, your maintenance strategy depends entirely on the iron parameters: 1, 2

If TSAT ≥20% and ferritin ≥100 ng/mL (Target Achieved):

• Switch to maintenance dosing: 25-100mg iron sucrose every 1-2 weeks (not the full 100mg every 2 weeks you proposed) 2
• The goal is to provide 250-1000mg total iron within any 12-week period 2
• Your proposed "100mg every 2 weeks" would deliver 600mg per 12 weeks, which falls within this range and is acceptable 2

If TSAT <20% or ferritin <100 ng/mL (Target Not Achieved):

• Administer a second 10-dose course of 100mg per session 1, 2
• Reassess 7 days after completing the second course 2

If TSAT >50% or ferritin >800 ng/mL (Overload Risk):

• Immediately stop all iron supplementation 2, 6
• Recheck parameters in 2-4 weeks 6
• Resume at one-third to one-half the previous dose only when TSAT falls below 50% 2, 6

Ongoing Monitoring Schedule

Once target hemoglobin is achieved and patient is on maintenance iron: 1

• Check TSAT, ferritin, and CBC every 3 months 1, 2
• If iron parameters remain stable (TSAT 20-50%, ferritin 100-800 ng/mL), continue quarterly monitoring 1, 2
• Weekly doses of 100-125mg or less do not need to be interrupted to obtain accurate iron measurements 1

Expected Clinical Response

• Hemoglobin should begin rising after 3 doses (approximately 3 weeks) and continue improving through 5 weeks after the 10th dose 4
• If no hemoglobin increase occurs despite achieving TSAT ≥20% and ferritin ≥100 ng/mL after the first course, proceed with the second 10-dose course before concluding the patient is iron-refractory 1, 2
• The National Kidney Foundation guidelines indicate patients are unlikely to respond further once TSAT exceeds 50% or ferritin exceeds 800 ng/mL 1, 2

Key Safety Considerations

• Iron sucrose 100mg per dose has an excellent safety profile with no serious adverse events reported, even in patients with prior iron dextran sensitivity 4, 5
• No test dose is required for iron sucrose 3, 4
• The regimen can be administered safely during the first hour of dialysis 3