ESRD patient with anemia, Fe sats of
12%, Ferritin 450 needs IV iron. Patient has bacteremia.
A. Proceed to give IV iron as anemia
and low Fe sats demands it. (2%)
B. Given active infection, do not
give IV iron till 2 weeks after infection resolved (73%)
C. Given active infection, do not
give IV iron till 4 weeks after infection resolves. (24%)
There have been no clinical trials of
adequate sample size and duration to provide us sufficient understanding of the
safety of intravenous iron. Is bolus iron better or continuous form? Is iron
infusion pose an infection risk?
Brookhart
et al. retrospectively studied patients on dialysis treated at Davita Inc. dialysis
facilities and found that patients receiving 200mg intravenous iron per month
had an increased risk for hospitalization or death because of infection. They
also found that bolus dosing was more associated with infection. More recently,
A CJASN study by Miskulin
et al. found a increased risk for infection-related mortality when
cumulative iron dose exceeded 1050 mg over 3 months or 2100 mg over 6 months(
not statistical but a trend). In an accompanying editorial to the Miskulin
study, Fishbane
et al (must read) discuss what the USRDS data suggests. As the mean serum ferritin
of United States patients on dialysis approximately doubled from 1993 to 2001,
the rate of bacteremia/sepsis increased approximately by 40%. From 2001 to 2010,
serum ferritin stabilized, and soon enough the bacteremia/sepsis rate also
stabilized. In light of these above findings, it is advisable to hold iron
infusions in setting of active bacteremia.
What about other active infections such as cellulitis or pneumonias? No
data exists for those at this point. How long do we wait is a good question.
Most likely choice is 2 weeks but data for that is not clear. Some of you chose
4 weeks: might also be a reasonable choice.
Another concern might be catheter use.
Infection risk as stated by the Brookhart study that risks are largest
among patients with a catheter and the ones with a recent infection.
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