IV Iron Therapy for CKD Anemia with Heart Failure

Assessment of Iron Status

Iron deficiency in CKD with heart failure should be evaluated by measuring ferritin and transferrin saturation, with absolute iron deficiency defined as transferrin saturation ≤20% with serum ferritin ≤100 μg/L in predialysis/peritoneal dialysis patients or ≤200 μg/L in hemodialysis patients, as recommended by the American Journal of Hematology 1, 2
Iron deficiency in heart failure is defined as ferritin <100 μg/L or ferritin 100-300 μg/L with transferrin saturation <20%, according to the American Journal of Hematology and Gut 2, 3
Patients should be screened for gastrointestinal causes of iron deficiency when absolute iron deficiency is present, with decisions about endoscopic evaluation made in conjunction with nephrology and cardiology teams, as suggested by Gut 2

Iron sucrose is approved for CKD patients, administered as slow IV infusion at maximum 200 mg per dose, no test dose required, as indicated by the American Journal of Hematology 1, 4
Ferric gluconate is indicated for CKD patients, given as slow IV infusion at maximum 125 mg per dose, no test dose required, according to the American Journal of Hematology 1, 4
Ferumoxytol is approved for CKD patients, given as 510 mg initial dose followed by second 510 mg dose, no test dose required, as recommended by the American Journal of Hematology 1, 4
Low molecular weight iron dextran requires test dose due to risk of anaphylaxis, as indicated by the American Journal of Hematology 4, 5

For CKD patients on hemodialysis, proactive monthly administration of 400 mg IV iron in patients with serum ferritin <700 μg/L and TSAT ≤40% is recommended based on the PIVOTAL trial, as suggested by Kidney International 6, 7

Multiple clinical trials have demonstrated that IV iron therapy in heart failure patients with iron deficiency improves exercise capacity, as shown by the American Journal of Hematology 1, 3, 4
IV iron therapy in heart failure patients with iron deficiency improves NYHA functional class and quality of life, according to the American Journal of Hematology 3, 4
IV iron therapy reduces heart failure hospitalizations, as demonstrated by Kidney International 6, 7
Benefits of IV iron therapy are seen regardless of anemia status, as suggested by Kidney International 6, 7

IV iron is preferred over oral iron in CKD patients with heart failure because oral iron may be poorly absorbed due to gut edema in heart failure, as indicated by Gut and Kidney International 2, 6
Oral iron frequently causes side effects, such as gastrointestinal irritation and constipation, as reported by the American Journal of Hematology 5
IV iron has demonstrated superior efficacy in improving heart failure symptoms, according to the American Journal of Hematology 3, 4

Withhold IV iron during active infections as these patients were excluded from clinical trials, as recommended by Kidney International 6, 7
While there are theoretical concerns about iron promoting oxidative stress or increasing infection risk, data from the PIVOTAL trial are reassuring regarding the safety of IV iron at doses used in clinical practice, as suggested by Kidney International 6, 7

Evaluate iron status (TSAT and ferritin) at least every 3 months during therapy, as recommended by Kidney International 8
Test iron status more frequently when initiating or increasing ESA dose, when there is blood loss, or when monitoring response after IV iron administration, according to Kidney International 8