Iron Supplementation in Chronic Kidney Disease

Introduction to Iron Supplementation

The American Society of Nephrology recommends that patients with chronic kidney disease (CKD) can and should receive iron supplementation when indicated, with the route of administration determined by CKD stage, iron parameters, and clinical context 1, 2

Iron supplementation should be started when specific laboratory thresholds are met, such as TSAT ≤30% AND ferritin ≤500 ng/mL, if the goal is to increase hemoglobin without starting erythropoiesis-stimulating agents (ESAs) 1, 3

The National Kidney Foundation recommends that intravenous iron is the preferred first-line choice when feasible for non-dialysis CKD patients, though a 1-3 month trial of oral iron is an acceptable alternative 1, 3
The European Renal Association recommends that intravenous iron is strongly preferred over oral iron for hemodialysis patients, as these patients have severely impaired intestinal iron absorption, greater ongoing iron losses, and higher iron requirements to support ESA-driven erythropoiesis 5

The American College of Physicians recommends that oral iron should be taken on an empty stomach without food or other medications for maximum absorption, and to avoid food within 2 hours before or 1 hour after dosing 3
The use of ionic iron salts (ferrous sulfate, fumarate, or gluconate) is recommended as they are most cost-effective, with ferrous sulfate 325 mg = 65 mg elemental iron, ferrous fumarate 325 mg = 108 mg elemental iron, and ferrous gluconate 325 mg = 35 mg elemental iron 3

The American Society of Nephrology recommends that 100 mg IV iron per dialysis session can be used to minimize dose-related arthralgias/myalgias, with maintenance dosing of 250-1,000 mg within 12 weeks, administered thrice weekly, weekly, or every other week 5

The National Kidney Foundation recommends checking iron parameters (TSAT and ferritin) and hemoglobin every 3 months once treatment is established, and to reassess after a 1-3 month trial of oral iron, switching to IV iron if there is an inadequate response 3, 6

The European Renal Association recommends withholding IV iron during active infections, as these patients were excluded from clinical trials and iron is essential for microbial growth 2, 4
The American College of Physicians recommends avoiding excessive iron administration, stopping when ferritin exceeds 500 ng/mL or TSAT exceeds 50%, and using high-dose strategies with caution 2, 4, 6