Iron Supplementation in Chronic Kidney Disease

Introduction to Iron Management

The Kidney International guidelines recommend intravenous iron therapy over oral iron for patients with severe chronic kidney disease (CKD), as oral iron is poorly absorbed and ineffective at maintaining adequate iron stores and hemoglobin levels, particularly in those with severe disease 1, 2, 3, 4

The American Journal of Kidney Diseases suggests that iron therapy is indicated when transferrin saturation (TSAT) is ≤30% and ferritin is ≤500 ng/mL, if the goal is to increase hemoglobin without erythropoiesis-stimulating agent (ESA) therapy 1
A ferritin level >100 ng/mL suggests adequate iron stores in non-dialysis CKD patients, though functional iron deficiency can still exist with normal ferritin if TSAT is low, according to the American Journal of Kidney Diseases 2

The Kidney International guidelines recommend measuring TSAT immediately to complete the iron status assessment, as iron therapy decisions require both ferritin and TSAT values together 1, 5, 6
Administering IV iron as a trial therapy with the goal of increasing hemoglobin without starting ESA treatment is recommended when TSAT is ≤30%, as per the Kidney International guidelines 1, 5

The Kidney International guidelines suggest checking iron parameters (TSAT and ferritin) every 3 months once treatment is established, and monitoring hemoglobin at least every 3 months in CKD patients with anemia not on ESA therapy 1, 2, 5
The American Journal of Kidney Diseases recommends avoiding excessive iron supplementation, withholding IV iron if ferritin exceeds 500 ng/mL or TSAT exceeds 50% 1, 5, 6