Iron Supplementation in Chronic Kidney Disease

Primary Recommendation

• The National Kidney Foundation recommends iron supplementation for CKD patients with hemoglobin < 110 g/L when ferritin is < 100 ng/mL or transferrin saturation (TSAT) is < 20%, with intravenous iron being the preferred route for hemodialysis patients and either IV or oral iron acceptable for non-dialysis CKD patients 1, 2

Assessment of Iron Status

• The American Society of Nephrology suggests measuring both ferritin and TSAT to determine the type and severity of iron deficiency before initiating iron therapy 3

Route of Administration by CKD Stage

Hemodialysis Patients (CKD Stage 5D)

• The American Journal of Kidney Diseases recommends intravenous iron as the preferred and necessary route for hemodialysis patients, with initial dosing of 100-125 mg IV per hemodialysis session for 8-10 consecutive sessions 5, 6, 7
• The American Journal of Kidney Diseases suggests maintenance dosing of 25-125 mg IV weekly once target iron indices are achieved 5, 7

Non-Dialysis CKD (Stages 3-5) and Peritoneal Dialysis

• The Kidney International Supplements suggests that either IV or oral iron is acceptable for non-dialysis CKD patients, though IV iron is preferred when feasible 8
• The American Journal of Kidney Diseases recommends an oral iron trial of 200 mg elemental iron daily for adults for 1-3 months 5, 8

Target Iron Indices

• The Kidney International Supplements recommends maintaining ferritin ≥ 100 ng/mL and TSAT ≥ 20% during treatment 1, 2, 9
• The American Journal of Kidney Diseases suggests stopping iron when ferritin > 500-800 ng/mL or TSAT > 50% 7, 5

Special Consideration: High Ferritin with Low TSAT

• The Kidney International Supplements recommends considering IV iron administration in patients with ferritin 500-1,200 ng/mL but TSAT < 25% who are below target hemoglobin or requiring high ESA doses 1, 2, 4

Monitoring Schedule

• The American Journal of Kidney Diseases recommends checking TSAT and ferritin monthly in patients not receiving IV iron and every 3 months in patients receiving IV iron 5, 3, 8
• The American Journal of Kidney Diseases suggests monitoring hemoglobin weekly until stable, then monthly 7

Safety Considerations

• The American Journal of Kidney Diseases recommends observing patients for at least 30 minutes after IV iron administration for hypersensitivity reactions 5
• The Praxis Medical Insights suggests monitoring for signs and symptoms of hypotension during and after each IV iron administration 8