IV Iron Sucrose is NOT Contraindicated in Hypertensive CKD
IV iron sucrose is safe and appropriate for use in patients with hypertensive chronic kidney disease, with no specific contraindication related to hypertension. 1
Evidence from FDA Labeling and Guidelines
The FDA-approved labeling for iron sucrose (Venofer) explicitly includes patients with CKD across all stages—hemodialysis-dependent (HDD-CKD), peritoneal dialysis-dependent (PDD-CKD), and non-dialysis-dependent (NDD-CKD)—with no mention of hypertension as a contraindication. 1 Multiple clinical trials in the FDA labeling enrolled patients with various CKD etiologies, including hypertensive nephropathy, without excluding hypertensive patients. 1
Safety Profile in CKD Populations
Iron sucrose has a superior safety profile compared to iron dextran and does not require a mandatory test dose. 2 The most common adverse events include:
- Hypotension and hypertension (both can occur, typically mild)
- Nausea, vomiting, diarrhea
- Headache, dizziness
- Pain, fever, dyspnea, pruritus 3
Importantly, blood pressure changes during iron sucrose infusion are typically minor and do not require rate adjustment. 4 In a study of 107 CKD patients receiving high-dose iron sucrose (500 mg over 3 hours on consecutive days), blood pressure rose slightly but not significantly, and no infusion rate alterations were necessary. 4
Recommended Dosing Regimens
For hemodialysis patients: 100 mg IV during consecutive dialysis sessions for a total of 1000 mg over 10 weeks, followed by maintenance therapy of 25-125 mg weekly. 2
For non-dialysis CKD patients: Either 200 mg over 2-5 minutes given 5 times within 14 days, or two 500 mg infusions on Day 1 and Day 14 administered over 3.5-4 hours. 1
For peritoneal dialysis patients: 300 mg in 250 mL normal saline over 1.5 hours on Days 1 and 15, and 400 mg in 250 mL normal saline over 2.5 hours on Day 29. 1
Clinical Efficacy Evidence
IV iron sucrose is superior to oral iron in CKD patients. 5 In a randomized controlled trial of non-dialysis CKD patients, 44.3% of those receiving IV iron sucrose achieved hemoglobin increase ≥1 g/dL compared to only 28% receiving oral iron (p=0.0344). 5 Additionally, patients receiving oral iron showed greater decline in GFR during the study (-4.40 vs -1.45 mL/min/1.73m², p=0.0100). 5
Important Safety Considerations
Withhold IV iron during active bacteremia or severe infection. 6, 2 Patients with active infection were excluded from clinical trials, and iron may theoretically support bacterial growth. 6
Avoid doses above 300 mg per administration for iron sucrose. 3 Research shows that 200-300 mg doses over 2 hours are safe, while 500 mg doses caused adverse reactions in 8 of 22 patients. 4
Monitor iron parameters appropriately: Wait at least 7 days after doses of 200-500 mg before measuring transferrin saturation and ferritin for accurate results. 2
Common Pitfalls to Avoid
- Do not confuse iron sucrose with iron dextran: Iron dextran has higher anaphylaxis risk and requires mandatory test dosing, while iron sucrose does not. 2
- Do not exceed recommended single-dose limits: Individual doses above 300 mg are not recommended for iron sucrose due to increased adverse event rates. 3
- Do not measure iron parameters too soon after administration: This leads to falsely elevated values and inappropriate treatment decisions. 2
Rare but Serious Adverse Events
While extremely rare, anaphylactic reactions to iron sucrose can occur. 7 One case report documented cardiac arrest minutes after starting iron sucrose infusion in a CKD patient, requiring aggressive resuscitation with epinephrine. 7 However, this represents an exceptionally rare event, and iron sucrose remains one of the safest IV iron preparations available. 8
The presence of hypertension in a CKD patient does not alter the risk-benefit profile of iron sucrose therapy and should not preclude its use when clinically indicated for iron deficiency anemia. 1, 5