Thread by @Juajal

Treatment of Iron Deficiency Anemia in CKD and End-Stage Kidney Disease

1/ Everything you need to know about IDA in CKD/ESRD. Follow along as we break down this recent @KIreports review.

kireports.org/article/S2468-…

@NSMCInternship
#twittorial #Nephtwitter #medtwitter

2/ We will discuss..

1. Pathophys of IDA in CKD
2. Types and modes of iron repletion
3. Therapeutic targets

Lets start with a question to warm up…

What is the role of Hepcidin in anemia of CKD?

3/ Chronic inflammation + decreased clearance - ↑ hepcidin in CKD pts
Iron absorption starts → apical membrane of the GI tract. Released into the blood via the basolateral membrane through ferroportin

Hepcidin promotes degradation of Ferroportin ↓ the release of iron → blood

4/ So, how much iron do we actually need?

We use ferritin and Tsat to help guide us

The levels for non dialysis patients are not backed up by robust clinical trials, but evidence suggests that an aggressive approach is beneficial for our patients.

5/ What is your prefered mode (PO vs IV) of Iron replacement in CKD non dialysis patients?

6/ 1st choice for CKD non-dialysis patients is usually PO.

It is readily available without prescription
It is cheap and avoids the need for IV access

@NephMadness 2021 has a great article on Oral vs IV Iron, check it out!

ajkdblog.org/2021/03/01/nep…
@Nephronpower @nupur_nephron

7/ Below are the PO Iron formulations and their dosage.
The most commonly used is Ferrous Sulfate.

8/ What increase in Hb is expected with ferrous sulfate 100mg PO BID in 1 year?

9/ An international study compared IV ferric carboxymaltose vs ferrous sulfate 100mg PO BID.
Link to study: ncbi.nlm.nih.gov/pmc/articles/P…

10/ Link to the study here
ncbi.nlm.nih.gov/pmc/articles/P…

11/ Another study comparing ferric citrate to ferrous sulfate showed ferric citrate outperformed ferrous sulfate with no significant difference in adverse effects

Link for study here
cjasn.asnjournals.org/content/clinja…

12/ Despite all the PO options, I.V. Iron replacement is more effective than P.O. Iron

But It also showed significant side effects, with IV iron, like low BP and allergic reactions
Link for article here:
ncbi.nlm.nih.gov/pmc/articles/P…

13/ For these reasons i.v. is the preferred formulation for patients on hemodialysis.

ESPECIALLY because it is easier to administer due to existing vascular access.

14/ Now that we have discussed the different forms of iron repletion, the next question is what are the goals of iron therapy?

What is the ferritin and TSAT Threshold to replace?

Two big studies have tried to answer this question.

15/ Conclusion
IDA is common in CKD patients
↑ hepcidin →↓ bioavailable of iron

HIF 1α prolyl hydroxylase inhibitors might help ↓ hepcidin levels

PO vs IV depends on pts and tolerability
PO first for CKD/PD
HD pts benefit from proactive approach

kireports.org/article/S2468-…