Peters N O, Jay N, Cridlig J, Rostoker G, Frimat L
Department of Nephrology, University hospital, Vandoeuvre les Nancy, France.
Department of Medical Informatics, University hospital, Vandoeuvre les Nancy, France.
BMC Nephrol. 2017 Mar 20;18(1):97. doi: 10.1186/s12882-017-0513-x.
Intravenous iron is widely used to control anemia in dialysis patients and limits costs related to erythropoiesis-stimulating agents (ESA). Current guidelines do not clearly set upper limits for serum ferritin (SF) and transferrin saturation (TSAT). International surveys such as the Dialysis Outcomes and Practice Patterns Study (DOPPS) showed that this lack of upper limits potentially led nephrologists to prescribe iron infusions even for patients with a high SF. Recent publications have suggested a risk of short- and long-term adverse effects related to iron overload. We conducted a proof of concept study to assess the impact of reducing intravenous iron administration.
In a prospective 8-month study conducted in a hospital dialysis unit, we assessed the impact of a strategy designed to reduce iron infusions. Instead of the usual strategy targeting 30-50% TSAT irrespective of SF, intravenous iron was administered if and only if TSAT was below 20% and SF below 200 μg/L. Routine practices for ESA remained unchanged: hemoglobin target 10-12 g/dL; ESA delivered monthly and dose corrected by 25% as necessary; ESA discontinued temporarily if hemoglobin >13 g/dL; methoxy polyethylene glycol-epoetin beta generally used. Tests were ordered monthly to monitor hemoglobin. Intravenous iron was administered weekly and ESA monthly. Baseline and 6-month TSAT, SF and hemoglobin levels were compared.
Six-month data were available for 45 patients (31 M/14 F; 67.6 ± 14.0 y; 53.9 ± 85.7 months on dialysis). Patients experienced the following comorbidities: ischemic heart disease (n = 29, 44%), diabetes mellitus (n = 14; 31%), malignant disease (n = 11; 24%), transplantation (n = 11; 24%) and severe heart failure (n = 6; 13%). The mean weekly dose of iron declined from 77.8 ± 87.6 to 24.4 ± 52.9 mg per patient (p = 0.0003). SF decreased from 947.7 ± 1056.4 to 570.7 ± 424.4 μg/L (p = 0.0001), and TSAT from 41.5 ± 22.4 to 32.6 ± 13.7% (p = 0.01). Hemoglobin levels remained stable (11.13 ± 1.05 vs. 11.00 ± 1.16 g/dL, p = 0.54) as did ESA dose (126.4 ± 91.9 vs. 108.2 ± 112.7 μg/28 days, p = 0.07).
Our study suggests that a regular hemoglobin level can be maintained using regular ESA doses combined with intravenous iron doses adapted to TSAT and SF thresholds lower than those used in routine practice. This strategy reduces the risk of iron overload.
静脉铁剂被广泛用于控制透析患者的贫血，并限制与促红细胞生成素（ESA）相关的费用。当前指南未明确设定血清铁蛋白（SF）和转铁蛋白饱和度（TSAT）的上限。诸如透析结果和实践模式研究（DOPPS）等国际调查显示，缺乏上限可能导致肾病学家即使对SF较高的患者也开具铁剂输注处方。最近的出版物表明存在与铁过载相关的短期和长期不良反应风险。我们进行了一项概念验证研究，以评估减少静脉铁剂给药的影响。
在一家医院透析单元进行的为期8个月的前瞻性研究中，我们评估了一项旨在减少铁剂输注的策略的影响。与通常不管SF如何将TSAT目标设定为30%-50%的策略不同，仅在TSAT低于20%且SF低于200μg/L时才给予静脉铁剂。ESA的常规做法保持不变：血红蛋白目标为10-12g/dL；每月给予ESA，并根据需要将剂量校正25%；如果血红蛋白>13g/dL，则暂时停用ESA；一般使用甲氧基聚乙二醇促红细胞生成素β。每月进行检测以监测血红蛋白。每周给予静脉铁剂，每月给予ESA。比较基线和6个月时的TSAT、SF和血红蛋白水平。
45例患者（31例男性/14例女性；67.6±14.0岁；透析53.9±85.7个月）有6个月的数据。患者有以下合并症：缺血性心脏病（n=29，44%）、糖尿病（n=14；31%）、恶性疾病（n=11；24%）、移植（n=11；24%）和严重心力衰竭（n=6；13%）。每位患者的平均每周铁剂量从77.8±87.6mg降至24.4±52.9mg（p=0.0003）。SF从947.7±1056.4μg/L降至570.7±424.4μg/L（p=0.0001），TSAT从41.5±22.4%降至32.6±13.7%（p=0.01）。血红蛋白水平保持稳定（11.13±1.05 vs. 11.00±1.16g/dL，p=0.54），ESA剂量也保持稳定（126.4±91.9 vs. 108.2±112.7μg/28天，p=0.07）。
我们的研究表明，使用常规ESA剂量并结合根据低于常规实践中使用的TSAT和SF阈值调整的静脉铁剂剂量，可以维持正常的血红蛋白水平。该策略降低了铁过载的风险。
