A Comprehensive Vision for Intravenous Iron Therapy

Commonly used iron indices, such as serum ferritin and transferrin saturation (TSAT), have limited utility in patients with chronic kidney disease. Both dialysis and nondialysis patients may have normal to high serum ferritin levels and little or no iron available for erythropoiesis. Inflammation can result in increased serum ferritin level and low TSAT and restrict the ability to mobilize iron stores. Management of anemia in patients with chronic kidney disease requires recognizing that not only decreased erythropoietin production, but also decreased iron availability, can lead to anemia. The Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) trial showed the efficacy of intravenous (IV) iron in anemic hemodialysis patients with serum ferritin levels of 500 to 1,200 ng/mL and TSAT of 25% or less receiving adequate erythropoiesis-stimulating agent doses. Withholding iron from these patients resulted in worsening iron-restricted erythropoiesis. To improve anemia management in patients receiving hemodialysis and being treated with ESAs, clinicians should consider the benefits of IV iron.