Guideline 2.1 – Treatment of Anaemia with Iron therapy – Iron Repletion:
We recommend that people should be iron replete to achieve and aim to maintain target Hb range, whether receiving ESA or HIF-PHI or not. (1B)
Iron repletion is usually defined as:
- %HRC <6% / CHr or RET-He >31 pg / ferritin and TSAT (>100 microgram/L and >20%) in people with non-dialysis dependent CKD (NDD-CKD) or on PD and >200 microgram/L in people on HD. (2B)
- A target ferritin level greater than 100 microgram/L for children with CKD on dialysis as well as children with CKD not on ESA or HIF-PHI therapy. (not graded)
- In ensuring iron repletion, iron should be considered when ferritin is <500 mcg/L and/or the TSAT <30%.
Guideline 2.2 – Treatment of Anaemia with Iron Therapy – Initiation of ESA/HIF-PHI and Iron Status:
We recommend that people on ESA or HIF-PHI therapy should remain iron replete before and during therapy either with oral iron or intravenous iron. (1B)
Guideline 2.2.1
We recommend that ESA or HIF-PHI therapy should not be initiated in the presence of absolute iron deficiency (ferritin <100 mcg/L in NDD-CKD and <200 mcg/L in DD-CKD) or functional Iron deficiency (TSAT <20% will normal or elevated ferritin levels) until this is corrected and anaemia persists. Iron supplements should be given prior to or when initiating ESA or HIF-PHI therapy. (1B)
Guideline 2.2.2
We suggest that to define functional iron deficiency (FID) (“iron restricted erythropoiesis”), a TSAT <20% and a normal or elevated ferritin in people with NDD-CKD or maintained on PD and in those receiving HD be used. Normal or high serum ferritin values do not exclude iron deficiency, as it could be due to other causes such as infection or inflammation. (2B)
Guideline 2.3 – Treatment of Anaemia with Iron Therapy – Route of Administration:
We suggest that for people with CKD not requiring HD, or people currently receiving PD who are being considered for ESA therapy, intravenous iron should be considered to reduce ESA dose requirements. (2B)
Guideline 2.3.1
We suggest for people with NDD-CKD or maintained on PD (i.e. not requiring HD), the choice between oral vs. parenteral iron depends on a shared decision and should include the impact of the severity of iron deficiency, the previous response and side effects, the availability of venous access and the need to initiate ESA or HIF-PHI therapy. (2A)
Guideline 2.3.2
We recommend that most people receiving haemodialysis will require IV iron. (1A)
Guideline 2.3.3
We suggest when offering IV iron therapy to people not receiving in-centre HD, consider high dose, low frequency (HiD/LF) IV iron as the treatment of choice for adults and young people when trying to achieve iron repletion, considering all of the following (2B):
- Availability of venous access
- Preferences of the person with anaemia of CKD or, where appropriate, their family or carers
- Nursing and administration costs
- Cost of local drug supply
- Provision of resuscitation facilities
Guideline 2.3.4
We suggest the frequency of administration of HiD/LF IV iron for people with CKD not requiring HD and for people receiving PD needs to be tailored for each person as there are no clear data. (not graded)
Guideline 2.4 – Treatment of Anaemia with Iron Therapy – Upper Limit for Iron Therapy:
For people not on HD, we recommend that serum ferritin should not exceed 600 mcg/L in those treated with iron. To achieve this, iron management should be reviewed when ferritin is >500 mcg/L, recognising that a level of >800 mcg/L may reflect iron toxicity. (1B)
Guideline 2.4.1
For people receiving HD, we recommend that proactive high-dose IV iron, initially 600 mg in divided doses in the first month and then 400 mg every month (or equivalent), should be given unless ferritin >700 mcg/L or TSAT >40%. (1A)
Guideline 2.4.2
We suggest a tailored approach by clinicians to assess the risk and benefit of starting a proactive IV iron protocol in people who have been established on HD for >12 months. (2B)
Guideline 2.5 – Treatment of Iron Deficiency without Anaemia:
We recommend for people with CKD with iron deficiency without anaemia and concomitant heart failure, administration of IV iron to improve well-being, physical function and to reduce heart failure admissions. (1A)
Guideline 2.5.1
We suggest for people with CKD with iron deficiency but without anaemia and no concomitant heart failure, a trial of oral or IV iron for improvement in clinical symptoms such as restless legs. (2B)
Guideline 2.6 – Administration of IV Iron – Safety Recommendations:
We recommend that resuscitative medication and personnel trained to evaluate and resuscitate be present in the event of anaphylaxis at each administration of intravenous iron. (1A)
Guideline 2.6.1
We recommend avoiding parenteral iron therapy in people with active infection. (1C)
Guideline 2.6.2 We suggest avoiding iron therapy in people with the following conditions (not graded):
- Hepatitis C virus infection (Positive PCR test)
- Haemochromatosis
Guideline 2.6.3 We suggest caution in prescribing parenteral iron in people with (not graded):
- Chronic liver disease
- Heterozygous for any of the haemochromatosis genes (C282Y (c.845G>A), H63D (c.187C>G) and S65C (c.193A>T).
Guideline 2.6.4
We suggest choice of parenteral iron be tailored, considering the benefits and risks associated with available iron preparations. (2C)
Guideline 2.7 – Monitoring of Treatment – Iron Therapy:
We recommend regular monitoring of iron status (every 1-3 months) in people receiving intravenous iron to avoid toxicity (defined as a serum ferritin of > 800 mcg/L or TSAT >40%). (1B)
Guideline 2.7.1
We recommend that a serum ferritin consistently >800 mcg/L with no evidence of inflammation (normal CRP) is suggestive of iron overload or potential toxicty. (1B)