Iron Deficiency Management in CKD and Cancer

Introduction to Iron Deficiency Management

The Kidney International guideline recommends initiating IV iron as first-line therapy for CKD patients with iron deficiency (TSAT ≤30% and ferritin ≤500 ng/mL), with oral iron only acceptable for non-dialysis CKD patients as a 1-3 month trial 1, 2

The Annals of Oncology guideline recommends using IV iron for both absolute iron deficiency (ferritin <100 ng/mL) and functional iron deficiency in cancer patients, reserving oral iron for patients with both absolute iron deficiency and non-inflammatory conditions (CRP <5 mg/L) 3, 4, 5
The Kidney International guideline suggests that IV iron is superior to oral iron in CKD due to elevated hepcidin levels blocking intestinal iron absorption, making oral supplementation largely ineffective 1, 2

The Annals of Oncology guideline states that ESAs are only indicated for anemia from myelosuppressive chemotherapy with at least 2 additional months of planned chemotherapy, and are contraindicated when cure is the anticipated outcome 3, 4, 5
The Kidney International guideline recommends evaluating iron status before starting ESAs and administering supplemental iron when ferritin <100 mcg/L or TSAT <20% 1

The Praxis Medical Insights guideline recommends checking hemoglobin monthly once stable, and reducing ESA dose by 25% or more if hemoglobin rises >1 g/dL in 2 weeks 6, 7
The Praxis Medical Insights guideline suggests checking ferritin and TSAT every 3 months to detect functional iron deficiency before it impairs ESA response, and maintaining TSAT >20% and ferritin >100 ng/mL (non-dialysis/peritoneal dialysis) or >200 ng/mL (hemodialysis) 6, 7

The Kidney International guideline recommends stopping iron supplementation when ferritin >500 ng/mL, as there is insufficient evidence of benefit and increased risks 1, 6, 2
The Praxis Medical Insights guideline suggests withholding IV iron during active infections, as iron is essential for microbial growth 2

The Annals of Oncology guideline warns that using ESAs in cancer patients when cure is anticipated or without ongoing chemotherapy increases mortality 5
The Praxis Medical Insights guideline cautions against stopping oral iron when hemoglobin normalizes without continuing 3 additional months, resulting in inadequate iron store repletion and early recurrence 7