Challenge of effectively using erythropoiesis-stimulating agents and intravenous iron.

Clinicians who manage anemia in patients with chronic kidney disease, both on and off dialysis therapy, face several challenges: maintain stable hemoglobin (Hb) levels in their patients, avoid overshooting Hb targets, balance intravenous (IV) iron and erythropoiesis-stimulating agents (ESAs), and improve ESA response to use the lowest effective ESA dose. Special attention to ESA hyporesponsiveness, as well as the role of insufficient iron, is required. The efficacy of IV iron in managing these challenges, particularly in hemodialysis patients who have anemia despite adequate ESA doses, was shown in the randomized controlled Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) clinical trial and its 6-week follow-up extension study, DRIVE-II. These studies provide suggestive evidence of the ability of IV iron to reduce ESA requirements and maintain improved Hb levels in anemic hemodialysis patients with serum ferritin levels of 500 to 1,200 ng/mL and transferrin saturations of 25% or less.