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Anemia is a condition in which your blood has a lower than normal number of red blood cells and may contain low levels of hemoglobin!. Hemoglobin is an iron-rich protein that gives blood its red color!. This protein helps red blood cells carry oxygen from the lungs to the rest of the body

Anemia has three main causes: blood loss such as heavy menstrual bleeding; decreased or faulty red blood cell production in the bone marrow or iron deficiency; or high rates of red blood cell destruction or hemolysis!. !. These causes may be due to a number of diseases such as advanced kidney disease: end-stage kidney disease (ESRD) and CKD- chronic kidney disease , conditions, or other factors!.

Anemia Caused by Blood Loss

Red blood cells can be lost through bleeding, which can occur slowly over a long period of time, and can often go undetected!. This kind of chronic bleeding commonly results from the following:

Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis (inflammation of the stomach) and cancer
Use of nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin or Motrin
Menstruation and childbirth in women, especially if menstrual bleeding is excessive and if there are multiple pregnancies!.

That's why the use of NSAID or anti-inflammatory in your case of anemia is not advisable!.

If oral iron agents such as iron supplements-oral, Femiron, Feosol, Fer-In-Sol; Ferritin!.;epoetin alfa, Epogen, and Procrit; some doctors now resort to Iron IV therapy!. Actually, a study found that the use of oral in conjunction with IV is more effective!.


Intravenous iron sucrose therapy as an adjuvant treatment to erythropoiesis-stimulating agents (ESA) can help effectively battle anemia in peritoneal-dialysis (PD) patients and avoid or delay the need to increase the dosage of ESA, a new study has found!.


The randomized, multicenter controlled trial found IV iron in combination with ESA therapy is superior to ESA alone and increases hemoglobin, decreases the need for anemia intervention, and replenishes iron stores!.


Published online March 29, 2006, the study will appear in the May 2006 issue of the Clinical Journal of the American Society of Nephrology!. The study's first author is Dr Harmeet Singh (Western Nephrology and Metabolic Bone Disease, Lakewood, CO)!.


According to the authors, "in patients who underwent combined ESA and intravenous iron therapy, hemoglobin rose higher, interventions were fewer, and net epoetin-dose decrease was greater than in patients who were given ESA therapy alone!."


The 12-week prospective study included 121 patients from 21 centers in the US and Mexico!. Patients were randomized to one of two groups!. Group A, which included 75 patients, received IV iron plus ESA, and group B, which included 46 patients, received ESA alone
!.

Patients in Group A received 1 g of IV iron sucrose administered over one month 300 mg on days 1 and 15 administered over 1!.5 hours, and a final dose of 400 mg given over 2!.5 hours on day 29!.


The primary end point was improvement in hemoglobin concentration of >1!.0 g or more over baseline!. Secondary end points included decreased need for transfusion, an increase in ESA dose, or additional IV iron not outlined in the study protocol!. All outcomes were monitored for 70 days after initiation of treatment!.

Group A study subjects experienced a greater rise in hemoglobin compared with those in group B, indicating the efficacy of IV iron!.

Peak hemoglobin increase in PD patients on IV iron+EPO vs EPO alone

End point
EPO+IV iron
EPO alone
95% CI
p

Peak hemoglobin increase (g)
1!.3
0!.6
0!.3-1!.2
0!.0028


In addition, the need for anemia intervention therapies was much less in the IV-iron group and median time to anemia intervention was shorter in patients on ESA therapy alone -34 vs 59 days!. Furthermore, the authors report, there were greater improvements in iron stores in those treated with combination therapy!. The authors also report that IV iron therapy was safe and well tolerated, with no serious adverse reactions!.

Rate of anemia intervention in PD patients on IV iron+EPO vs EPO alone


Treatment group
Anemia intervention rate (%)

EPO+IV iron
1!.3

EPO alone
16!.7

The authors acknowledge that while IV iron therapy is more expensive than treatment with oral iron agents, the efficacy of oral iron therapy as an adjuvant treatment to ESA is "unclear!." Furthermore, they state that the ability of IV iron to prevent or delay the need for ESA an even more expensive treatment more than offsets the cost of IV iron!.

The authors conclude that IV iron therapy in PD patients is a well-tolerated therapy and "provides a practical approach to completing iron repletion expeditiously in the outpatient treatment center!.

Anemia is usually detected or at least confirmed by a complete blood cell (CBC) count esp the Hb ( hemoglobin)!.

The World Health Organization's criterion for anemia in adults is Hb values less than 12!.5 g/dL!.
And this has to be monitored thru the course of the therapy to evaluate the clinical iron status to avoid iron overload!.

The goal of the initial iron therapy is to replenish the body store of functional iron and thus assist in the production of red blood cells and Hb in concert with an ESA!. The exact dosing regimens, frequency of IV iron therapy, and appropriate monitoring for effectiveness and safety will be related to the iron preparation chosen

Targets of iron therapy: (APPLICABLE TO CHILDREN, BUT NEEDS MODIFICATION)
In the opinion of the Work Group, sufficient iron should be administered to generally maintain the following indices of iron status during ESA treatment:

3!.2!.3!.1 ADULT CPR HD-CKD:
? Serum ferritin > 200 ng/mL, AND
? TSAT > 20%, or CHr > 29 pg/cell!.
PEDIATRIC CPR
HD-CKD:
? Serum ferritin > 100 ng/mL; AND
? TSAT > 20%!.
3!.2!.3!.2 ND-CKD and PD-CKD:
? Serum ferritin > 100 ng/mL AND
? TSAT > 20%!.

Route of administration: (FULLY APPLICABLE TO CHILDREN)
The preferred route of administration is IV in patients with HD-CKD!.


Frequency of iron status tests: (FULLY APPLICABLE TO CHILDREN) should be performed :

Every month during initial ESA treatment!.
At least every 3 months during stable ESA treatment or in patients with HD-CKD not treated with an ESA

Dosing of IV Iron
The use of IV iron preparations and the appropriate dosage of each is a complex topic!. It is made more so because one needs an approach to both the immediate repletion of iron stores in a patient who is deficient and a strategy for maintaining an effective level of iron for ongoing erythropoiesis!.

The goal of the initial iron therapy is to replenish the body store of functional iron and thus assist in the production of red blood cells and Hb in concert with an ESA!. The exact dosing regimens, frequency of IV iron therapy, and appropriate monitoring for effectiveness and safety will be related to the iron preparation chosen

Adverse effects:
Constipation and nausea, as well as poor GI iron absorption, often limit effective supplementation with oral iron preparations!.These facts and the availability of newer IV iron preparations believed less likely to induce AEs ( adverse effects ) recently led to more studies with IV preparations of iron in children!. All forms of IV iron may be associated with acute AEs, which may include , isolated episode of mild nausea, diarrhea, and vomiting and hypotension,presumably caused by acute iron toxicity during rapid free iron release!.


Current evidence would suggest that the risk for life-threatening reactions is greater with IV dextran products than sodium ferric gluconate175 and iron sucrose products!.
Side effects from dextran are presumably caused by acute iron toxicity during rapid free iron release!.The issue of iron overload as a

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