Clinical Case 85: Answers and Summary ( iron use in ESRD)

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.