Proactive iron supplementation alone in patients on chronic hemodialysis is not sufficient

Dialysis patients often become iron-deficient because of many factors, including poor iron absorption from the gut, blood loss during dialysis, frequent blood draws, phosphate binders, and the use of erythropoietin. Oral supplementation is ineffective because of elevated hepcidin levels and low levels of iron-absorbing factors in the duodenal mucosa. Intravenous iron supplementation can be given in two forms: one is to replace iron when the iron content or total iron binding capacity saturation (FeSat) is too low, that is, a reactive dosing (RE); or by administering iron on a schedule of weekly proactive dosing (PRO), as recommended by guidelines. We investigated whether PRO alone is sufficient, as our hospital-based dialysis unit used a PRO schedule according to our current protocol. The data of 102 patients receiving a mean 107.7 ± 65.9 mg/week of intravenous iron (sodium ferric gluconate complex) were analyzed. Fifty-four of the 91 patients with complete datasets had an FeSat 25 (p = 0.0003). After 3 months of both PRO and RE dosing the mean ± standard deviation hemoglobin rose from 10.07 g/dL ±1.35 with PRO alone to 10.55 ± 1.70 (p:0.0008) using both schedules from FeSat: 24.2% ±14.1 and to 29.22% ±9.8 (p:0.0015). Thus, we conclude that the PRO regimen alone is not sufficient to maintain a healthy hemoglobin or FeSat level while using the same amount of erythropoietin.