Iron injection in managing anemia in CKD

Iron deficiency is frequent in people with chronic renal disease, and it plays a significant role in how anemia develops. Anemia is a common complication for people with kidney-related disorders such as chronic kidney disease (CKD). 


Anemia develops when the body does not create enough red blood cells, which deliver oxygen to the heart, brain, and other tissues and organs. Low red blood cell numbers can cause a variety of health problems. While there is no cure for CKD, injectable therapies can help reduce the disease’s course and address consequences such as anemia from the iron shortage.


The efficacy of oral iron agents can be reduced due to decreased iron absorption in the gastrointestinal tract and a high incidence of gastrointestinal side effects, necessitating i.v. Iron formulations to treat iron deficiency anemia, particularly in patients requiring kidney replacement therapy.


Iron deficiency anemia (IDA), a common consequence of chronic kidney disease (CKD), is still underdiagnosed and undertreated, especially in dialysis patients. Reduced dietary iron intake and poor intestinal absorption, blood losses, chronic inflammation, and increased iron needs during treatment with erythropoiesis-stimulating drugs are the major causes of IDA in this group (ESAs).


The administration of IV iron is recommended in clinical guidelines for anemia caused by CKD. When it comes to CKD anemia, there are many things to think about, and the different types of iron aren’t all the same.Iron deficiency anemia (IDA) is a common consequence of chronic kidney disease (CKD), especially in dialysis patients, and it is underdiagnosed and undertreated. 


Why does anemia occur in patients with CKD?


Chronic renal disease is defined as long-term kidney impairment in which the patient gradually loses kidney function. Without dialysis to filter the blood or, in some situations, a kidney transplant, severe stages of CKD can lead to complete renal failure. Anemia develops when your kidneys cannot generate the hormone erythropoietin (EPO), which aids in the production of red blood cells in your bone marrow. The body becomes anemic if enough quantities of EPO are not present, and it cannot give enough oxygen to the body.


Symptoms of Iron Deficiency in CKD


Fatigue, weakness, anorexia, sleeplessness, angina, tachycardia, dyspnea, impaired mental and physical function, and even heart failure are all symptoms of iron deficiency. 


IDA is underdiagnosed and undertreated, even though correcting anemia in CKD has been demonstrated to delay renal disease and enhance the overall quality of life.

Renal and hematologic test results should be examined yearly in individuals at risk since early-stage CKD and anemia are frequently asymptomatic. 


The incidence of anemia increases as the glomerular filtration rate (GFR) falls with increasing CKD, from around 27% in stage 1 to 76% in stage 5 (GFR 15 mL/min).


How Injection Therapy Works for Anemia in CKD


Anemia caused by CKD is treated with injections administered via the skin with a syringe (subcutaneously). It permits the drug to enter the bloodstream faster than oral pills, while it may take a few weeks for your body to start manufacturing new red blood cells if you have anemia. 


Successful injectable therapies will lessen the need for blood transfusions and other more invasive anemia treatments, as well as the frequency with which they are used.

Outcomes of Iron Deficiency Anemia in CKD. Anemia has been linked to an increased risk of morbidity and death in people with CKD. 


In primary observational research, 27998 individuals with CKD were tracked for around 5.5 years. The authors discovered that patients who died had a greater baseline frequency of anemia than those who survived. Furthermore, despite a shorter duration of observation, individuals who died had the most significant rise in the incidence of anemia across the observation period.


Iron and ESA Therapy


Despite its advantages, ESA medication is linked to an increased risk of ADEs such as cardiovascular (CV) problems, hypertension, RBC aplasia, and the formation of anti erythropoietin antibodies. 


Because of greater Hgb levels in hypo responders and higher ESA doses delivered to hypo responders, three studies (CHOIR, CREATE, and TREAT) highlighted concerns regarding ESA therapy and its related CV and mortality risks. For optimizing Hgb status and minimizing ESA dose requirements, 12-14 IV iron as an adjuvant to ESA therapy has become routine treatment.


Iron Supplementation

HD patients on ESA therapy should receive IV iron supplementation to maintain a target Hgb of 11 g/dL to 12 g/dL (not to exceed 13 g/dL), according to the 2006 and 2007 updates to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for anemia of CKD. 


According to the recommendations, patients who are not on dialysis or who are on peritoneal dialysis should have iron either orally or intravenously. Before starting ESA medication, iron repletion should be started. Iron levels should be checked weekly at first until iron reserves are restored, then quarterly.


Infusion Medications for Iron Deficiency Anemia in CKD


Aranesp (darbepoetin alfa) and Procrit (epoetin alfa) are the two most used injectable treatments for anemia in CKD patients. Both of these therapies are synthetic erythropoietin (EPO) stimulators, which enable your bone marrow to make red blood cells in the same way as natural EPO does. Successful Procrit or Aranesp treatments can increase hemoglobin levels and minimize the need for the frequency of blood transfusions.


The FDA recently licensed Retacrit (epoetin alfa-epabx) for the treatment of anemia caused by CKD. It’s a biosimilar product to Procrit, which implies no clinically significant difference between the two. If your healthcare provider approves the therapy, biosimilars may be a more cost-effective choice than the reference product.




Iron is a therapeutic option for CKD-related anemia that can effectively counteract the hazards of ESA medication. To reflect this, the KDOQI criteria were amended in 2007. 

Pharmacists should be aware that there are some considerations to consider while treating CKD-related anemia and that not all forms of iron are the same.

In patients with chronic renal disease who have been diagnosed with iron shortage, both oral and injectable iron treatments are available. 

Therapy aims, tolerability, convenience, and response to previous treatment are frequently used to determine which drug to employ. 


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