NIV 2014

Introduction: Efforts to decrease the use of costly and potentially harmful erythropoietin stimulating agents (ESAs) for treatment of anemia in hemodialysis (HD) patients have contributed to increased intravenous (IV) iron use in clinical practice. Administration of IV iron using a maintenance pattern has shown conflicting results with respect to anemia management including possible reduction of ESA use when compared with non-maintenance IV iron administration.

Aim of the study:To explore the association of maintenance versus non-maintenance IV iron administration with patients’ achievement of anemia management goals (hemoglobin (Hb) and ESA use) in a contemporary sample of adult HD patients.

Materials and Methods: We included patients who initiated chronic hemodialysis in Dialysis Clinic Inc. centers between 2003 and 2009 and who were eligible to receive predefined IV iron administration patterns. We defined maintenance as any regularly occurring pattern of IV iron administration and used logistic regression models to calculate the association between iron administration patterns and the achievement of an Hb target (10 to 12 g/dL) or a decrease of more than 25% in mean weekly ESA dose adjusted for body weight. The relation between iron administration patterns and mortality was studied in order to quantify the effect of differential drop-outs. All models were adjusted for variables representing clinical clusters responsible for potential confounding, based on clinical reasoning: demographic, clinical and treatment parameters (age, sex, race, ethnicity, cause of end stage renal disease, rGFR, BMI, comorbidity and year of dialysis initiation), iron dose (total iron dose during the exposure period), measures of iron stores (Hb, TSAT and ferritin at the start of the exposure period and mean weekly ESA dose during the exposure period) and recent history of pro-infectious and pro-inflammatory parameters (vascular access, serum albumin, serum creatinine and infection).

Results: The maintenance group included 4511 patients; non-maintenance 8458. Maintenance iron administration was not associated with achieving a Hb between 10-12g/dL [adjusted Odds Ratio (OR): 1.01 (95% Confidence Intervals (CI) 0.93-1.09)], less than 10g/dL [OR: 1.03 (95% CI 0.89-1.19)] or greater than 12g/dL [OR: 0.98 (95% CI 0.91-1.07)] compared with non-maintenance Hb. Maintenance administration was associated with a higher odds of achieving a 25% reduction in patients’ mean weekly ESA dose (1.15 (1.02-1.30) and lower mortality [OR 0.70 (95%CI 0.60 to 0.84)].

Conclusion: Maintenance administration of IV iron does not appear to be associated with achievement of target hemoglobin goals but may reduce patients’ESA requirements and mortality.