1. Intravenous Iron Supplementation and Chronic Kidney Disease Chloe Bierbower December 2, 2013

2. Definition of Evidence-Based Medicine Definition: ▫The integration of individual clinical expertise and the best external evidence when deciding how to care for patients. Pro: ▫Helps clinicians assess whether or not a treatment will help a patient or do more harm Con: ▫Results from studies may not be relevant for all treatment situations and applications

3. Non-Dialysis Chronic Kidney Disease and Iron Deficiency Anemia Iron deficiency is a common cause of anemia in ND-CKD patients Iron deficiency anemia inflicts patients with ND- CKD at all stages Decreased kidney function caused by CKD can cause iron deficiency anemia by: ▫Erythropoietin deficiency  Decreased red blood cell synthesis ▫Decreased use of nutritional and stored iron

4. Qunibi et al., 2010 Studied the efficacy of IV Ferric Carboxymaltose vs Oral Ferrous Sulfate in treating iron deficiency anemia in ND-CKD patients Methods ▫Open-label, randomized, controlled, multicenter trial (47 centers) ▫Subject criteria:   12 years of age, GFR  45 mL/min, Hb  11 g/dL, TSAT  25%, ferritin  300 ng/mL ▫147 people received FCM infusions of a maximum of 1000 mg over 15 mins ▫103 received 325 mg of oral ferrous sulfate 1 hour before meals 3 times daily ▫Study conducted over 8 weeks

5. IV Ferric Carboxymaltose is more effective than Oral Ferrous Sulfate in treating iron deficiency anemia in ND-CKD patients ▫134 from FCM group completed the study (91.2%) ▫84 from oral group completed the study (81.6%) ▫Intravenous FCM was more effective at treating anemia than oral ferrous sulfate ▫FCM increased repletion of iron stores better and faster than oral ferrous sulfate ▫Proportion of a drug-related adverse effects lower in FCM group than oral group Qunibi et al., 2010

7. Stancu et al., 2009 Studied the response to IV iron sucrose supplementation in treating iron deficiency anemia in ND-CKD patients Methods ▫3 month-long single center diagnostic study  2 months- admission criteria assessed  Baseline: bone marrow aspiration, TSAT, serum ferritin evaluated ▫Subject criteria:  Hb  11g/dL, Stages 3-5 CKD, GFR  60 mL/min  Excluded if have additional health conditions ▫100 adults (<18) received 1000mg of iron sucrose intravenously 5 days after baseline ▫Returned 1 month later  Evaluated Hb, TSAT, serum ferritin levels

8. Stancu et al., 2009 IV iron supplementation can be useful in managing anemia in ND-CKD patients ▫100% of patients completed study ▫Response defined as  1 g/dL increase in Hb ▫49 responders, 51 nonresponders ▫Mean Hb attained was 10g/dL  1.0 .4 g/dL mean increase ▫Responders were younger and a greater proportion of them were in Stage 4 CKD ▫~1/3 of responders showed iron-replete bone marrow stores

9. Stancu et al., 2009

10. Recommendation and Grades Intravenous iron supplementation is beneficial for ND-CKD patients with iron deficiency anemia Evidence ▫Qunibi et al. = A  Randomized controlled, multicenter trial  Short, no long term effects ▫Stancu et al. = C  Single-center, not randomized controlled  One of the largest studies, however, still relatively small sample size ▫Overall grade = B  Need more long-term studies  More evidence needed in type of IV iron used

11. Bibliography Stancu, S., Barsan, L., Stanciu, A., & Mircescu, G. (2009). Can the response to iron therapy be predicted in anemic nondialysis patients with chronic kidney disease?. Clinical Journal of the American Society of Nephrology, 5(3), 409-419. Retrieved from http://cjasn.asnjournals.org/content/5/3/409.fullhttp://cjasn.asnjournals.org/content/5/3/409.full Qunibi, W. Y., Martinez, C., Smith, M., Benjamin, J., Mangione, A., & Roger, S. (2010). A randomized controlled trial comparing intravenous ferric carboxymaltose with oral iron for treatment of iron deficiency anaemia of non-dialysis-dependent chronic kidney disease patients. Nephrology Dialysis Transplantation, 26(5), 1599- 1607. Retrieved from http://ndt.oxfordjournals.org/content/26/5/1599.shorthttp://ndt.oxfordjournals.org/content/26/5/1599.short Van Wyck, D. B., Roppolo, M., Martinez, C. O., Mazey, R. M., & McMurray, S. (2005). A randomized, controlled trial comparing IV iron sucrose to oral iron in anemic patients with nondialysis-dependent CKD. Kidney International, 68(6), 2846-2856. doi:10.1111/j.1523-1755.2005.00758.x