Can a patient with ovarian and breast cancer, anemia, impaired renal function, elevated ferritin, and low serum iron receive intravenous (IV) iron supplementation during chemotherapy?

IV Iron Administration in Cancer Patients with Renal Impairment

This patient should NOT receive IV iron at this time due to severe renal impairment (eGFR 25) and elevated ferritin (619 ng/mL) indicating iron overload risk, despite the low transferrin saturation suggesting functional iron deficiency. 1

Critical Laboratory Analysis

Your patient's iron studies reveal a complex picture:

• Ferritin 619 ng/mL: Well above the threshold for functional iron deficiency (>100 ng/mL) and approaching the upper safety limit of 800 ng/mL 1
• Transferrin saturation 30%: Above the 20% cutoff that defines functional iron deficiency 1
• Hemoglobin 9.5 g/dL: Moderate anemia requiring intervention 1
• MCV 109: Macrocytic anemia, suggesting potential B12/folate deficiency or chemotherapy effect 1

Why IV Iron is Contraindicated Here

Iron Status Assessment

This patient is NOT iron deficient by guideline criteria. 1

• Functional iron deficiency is defined as TSAT <20% AND ferritin 100-800 ng/mL 1
• Your patient has TSAT of 30% (above threshold) and ferritin 619 ng/mL 1
• When ferritin >800 ng/mL OR TSAT ≥20%, IV iron supplementation is not needed 1

Severe Renal Impairment Concerns

The eGFR of 25 mL/min (Stage 4 CKD) creates additional risks:

• While chronic kidney disease patients may require IV iron, this is typically in the context of dialysis-dependent patients with different iron metabolism 2
• The combination of elevated ferritin and severe renal impairment increases risk of iron overload complications 1
• No guideline evidence supports IV iron administration in cancer patients with this degree of renal impairment and elevated ferritin 1

Infection Risk with Neutropenia

• WBC 2.8 indicates neutropenia from chemotherapy 1
• IV iron should not be administered during periods of neutropenia since infused iron may be used by microorganisms 1
• Meta-analysis demonstrated significantly increased infection risk (RR 1.33) with IV iron compared to oral or no iron 1

Recommended Management Approach

Immediate Actions

Address the macrocytic anemia first:

• Check serum folate and vitamin B12 levels immediately 1
• If folate <3.4 ng/mL: administer folic acid 1-5 mg PO daily for 3 months 1
• If B12 deficient: administer vitamin B12 2000 mcg PO daily for 3 months 1
• The MCV of 109 strongly suggests nutritional deficiency rather than pure iron deficiency 1

Anemia Management Options

For Hgb 9.5 g/dL in a chemotherapy patient: 1

1. RBC transfusion is appropriate if symptomatic (tachycardia, tachypnea, postural hypotension) with goal Hgb 8-10 g/dL 1
2. ESA therapy can be considered with informed consent under REMS guidelines, as patient has chemotherapy-induced anemia without iron deficiency 1
3. Monitor and supportive care if asymptomatic, as Hgb >7-8 g/dL 1

When to Reconsider IV Iron

IV iron would only be appropriate if: 1

• Ferritin drops below 100 ng/mL (absolute iron deficiency) 1
• OR TSAT drops below 20% AND ferritin remains 100-800 ng/mL (functional iron deficiency) 1
• AND WBC recovers above neutropenic range 1
• AND patient is actively receiving chemotherapy 1

Critical Pitfalls to Avoid

• Do not administer IV iron based solely on low serum iron (79) - this must be interpreted with TSAT and ferritin 1
• Do not give IV iron on the same day as anthracyclines due to potential cardiotoxicity potentiation 1
• Do not ignore the macrocytic anemia - this suggests a different etiology requiring vitamin supplementation 1
• Do not overlook the severe renal impairment - creatinine 2.19 and eGFR 25 require nephrology consultation for anemia management in this complex patient 1