From the Guidelines
For patients with chronic kidney disease (CKD), the target ferritin level should not exceed 500 ng/mL to avoid potential complications of iron overload, as evidenced by the most recent study 1.
Key Considerations
- The upper limit of ferritin is crucial in preventing iron overload, which can lead to increased morbidity and mortality in CKD patients.
- Iron supplementation should be considered when ferritin falls below 100 ng/mL in non-dialysis CKD patients or below 200 ng/mL in dialysis patients.
- Options for supplementation include oral iron or intravenous iron for those who cannot tolerate oral preparations or have severe iron deficiency.
- Regular monitoring of ferritin levels every 1-3 months is recommended during treatment.
Iron Overload Risks
- High ferritin levels (above 500 ng/mL) have been associated with increased risk of cardiovascular events, infections, and mortality in CKD patients 1.
- Iron overload can lead to oxidative stress, inflammation, and disruption of homeostasis of iron-regulating hormones, ultimately contributing to accelerated morbidity and mortality.
Monitoring and Treatment
- Ferritin levels should be interpreted alongside transferrin saturation (TSAT), with a target TSAT of 20-30%.
- Maintaining appropriate iron stores is crucial for effective response to erythropoiesis-stimulating agents and managing anemia in CKD patients.
- The most recent study 1 suggests that high-dose IV iron may increase mortality and cardiovascular events in hemodialysis patients, emphasizing the need for careful monitoring and dose adjustment.
From the Research
High Ferritin Levels in CKD
- High ferritin levels in patients with Chronic Kidney Disease (CKD) can be misleading as they may not always indicate iron overload 2.
- Serum ferritin levels >500 ng/ml are common in maintenance hemodialysis patients, but this may be due to non-iron related conditions such as inflammation, malnutrition, liver disease, infection, and malignancy 2.
- Some studies suggest that a serum ferritin level <1200 ng/ml and an iron saturation ratio in the 30-50% range are associated with the greatest survival in maintenance hemodialysis patients 2.
Upper Limit for Iron Treatment
- International treatment guidelines generally recommend discontinuing intravenous iron treatment when serum ferritin is greater than 500-1000 ng/ml 3.
- However, the current published literature is inadequate for developing evidence-based guidelines, and clinical judgment is critical in weighing the risks and benefits of intravenous iron treatment 3.
Management of Anemia in CKD
- The Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients, including therapy with erythropoiesis stimulating agents (ESA) and iron therapy 4.
- Anemia treatment with either erythropoietin or erythropoiesis-stimulating agents has failed to induce a prognostic benefit in CKD patients, but liberal intravenous iron supplementation has been beneficial in chronic dialysis patients 5.