Rostoker Guy
Ramsay-Générale de Santé, Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Quincy sous Sénart, France.
Semin Dial. 2019 Jan;32(1):22-29. doi: 10.1111/sdi.12732. Epub 2018 Jun 28.
Parenteral iron is used to restore the body's iron pool before and during erythropoiesis-stimulating agent (ESA) therapy; together these agents form the backbone of anemia management in end-stage renal disease (ESRD) patients undergoing hemodialysis. ESRD patients receiving chronic intravenous iron products, which exceed their blood loss are exposed to an increased risk of positive iron balance. Measurement of the liver iron concentration (LIC) reflects total body iron stores in patients with secondary hemosiderosis and genetic hemochromatosis. Recent studies of LIC in hemodialysis patients, measured by quantitative MRI and magnetic susceptometry, have demonstrated a high risk of iron overload in dialysis patients treated with IV iron products at doses advocated by current anemia management guidelines for dialysis patients. Liver iron overload causes increased production of hepcidin and elevated plasma levels, which can activate macrophages of atherosclerotic plaques. This mechanism may explain the results of 3 long-term epidemiological studies which showed the association of excessive IV iron doses with increased risk of cardiovascular morbidity and mortality among hemodialysis patients. A more physiological approach of iron therapy in ESRD is needed. Peritoneal dialysis patients, hemodialysis patients infected with hepatitis C virus, and hemodialysis patients with ferritin above 1000 μg/L without a concomitant inflammatory state, all require specific and cautious iron management. Two recent studies have shown that most hemodialysis patients will benefit from lower maintenance IV iron dosages; their results are applicable to American hemodialysis patients. Novel pharmacometric and economic approaches to iron therapy and anemia management are emerging which are designed to lessen the potential side effects of excessive IV iron while maintaining hemoglobin stability without an increase in ESA dosing.
胃肠外铁剂用于在促红细胞生成素（ESA）治疗前及治疗期间恢复机体铁储备；这两种药物共同构成了接受血液透析的终末期肾病（ESRD）患者贫血管理的基础。接受超过其失血量的慢性静脉铁剂治疗的ESRD患者面临铁正平衡风险增加的问题。肝铁浓度（LIC）的测量反映了继发性血色素沉着症和遗传性血色素沉着症患者的全身铁储备情况。最近通过定量MRI和磁测法对血液透析患者的LIC进行的研究表明，按照目前透析患者贫血管理指南所倡导的剂量使用静脉铁剂治疗的透析患者存在铁过载的高风险。肝铁过载会导致铁调素生成增加和血浆水平升高，进而激活动脉粥样硬化斑块中的巨噬细胞。这一机制可能解释了3项长期流行病学研究的结果，这些研究表明，过量静脉铁剂剂量与血液透析患者心血管发病率和死亡率增加之间存在关联。ESRD患者需要一种更符合生理的铁剂治疗方法。腹膜透析患者、感染丙型肝炎病毒的血液透析患者以及铁蛋白高于1000μg/L且无伴随炎症状态的血液透析患者，都需要进行特定且谨慎的铁管理。最近的两项研究表明，大多数血液透析患者将从较低剂量的维持性静脉铁剂中获益；其结果适用于美国血液透析患者。旨在减少过量静脉铁剂潜在副作用同时在不增加ESA剂量的情况下维持血红蛋白稳定性的新型铁剂治疗和贫血管理的药代动力学及经济学方法正在不断涌现。
