Resolving the paradigm crisis in intravenous iron and erythropoietin management  A. Besarab  Kidney International  Volume 69, Pages S13-S18 (May 2006) DOI: 10.1038/sj.ki.5000405 Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 1 Trends in i.v. iron usage among US hemodialysis patients, 1994–2002. Although nearly 85% of all hemodialysis patients on EPO therapy received i.v. iron at least once during 2002, only 55% received i.v. iron at least monthly, indicating a failure to implement routine i.v. iron continued protocols as established by the K/DOQI guidelines.2 Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 2 Functional iron deficiency following the initiation of EPO therapy. The supraphysiologic rate of erythropoiesis with EPO results in a depleted pool of storage iron, as iron is moved into the erythroid marrow for incorporation into new red blood cells. Hgb, hemoglobin; HD, hemodialysis. Adapted from Excerpta Medica International Congress Series No. 366, 1975, pp 190–98.6 Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 3 Graphic representation of intermittent repletion (solid bar) versus repletion followed by ongoing (dotted line) approaches to i.v. iron therapy. An intermittent repletion regimen results in a ‘rollercoastering’ effect on iron stores. Reprinted with permission from Nephron 1999; 81: 362–363.8 Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 4 Change in mean Hgb levels with a continued low-dose regimen of sodium ferric gluconate versus an intermittent regimen. Reprinted with permission from Am J Nephrol 2002; 22: 67–72.17 Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 5 I.v. iron expenditures compared with reductions in EPO requirements with an aggressive i.v. iron continued regimen (100 mg/week via bolus). Although i.v. iron expenditures increased in this population of 116 hemodialysis patients by $38 500, the reduction in EPO dosages translated into a net cost savings of $362 000. Adapted with permission from Am J Kidney Dis 1999; 34(Suppl 2): S40–S46.18 Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions

Figure 6 Continued iron therapy and anemia management protocol used by the Henry Ford Health System. TSAT, transferrin saturation. Kidney International 2006 69, S13-S18DOI: (10.1038/sj.ki.5000405) Copyright © 2006 International Society of Nephrology Terms and Conditions