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Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions.

ABSTRACT: Current recommendations for the use of intravenous iron therapy in the management of anaemia in patients with chronic kidney disease (CKD) are based on limited clinical evidence. Since the publication of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anaemia in Chronic Kidney Disease in 2012, a number of randomized clinical trials [notably, the Ferinject Assessment in Patients with Iron Deficiency Anaemia (FIND-CKD) and Randomized Trial to Evaluate IV and Oral Iron in Chronic Kidney Disease (REVOKE) trials] and observational studies have been completed, and a further large clinical trial-Proactive IV Iron Therapy in Dialysis Patients (PIVOTAL)-is currently underway. In this article, the implications of the findings from these recent studies are discussed and the critical evidence gaps that remain to be addressed are highlighted.

SUBMITTER: Macdougall IC

PROVIDER: S-EPMC5716151 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions.

Macdougall Iain C IC

Clinical kidney journal 20171128 Suppl 1

Current recommendations for the use of intravenous iron therapy in the management of anaemia in patients with chronic kidney disease (CKD) are based on limited clinical evidence. Since the publication of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anaemia in Chronic Kidney Disease in 2012, a number of randomized clinical trials [notably, the Ferinject Assessment in Patients with Iron Deficiency Anaemia (FIND-CKD) and Randomized Trial to Evaluate IV and O ...[more]

PMID: 29225819

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Project description:Anaemia in chronic kidney disease (CKD) is managed primarily with erythropoiesis-stimulating agents (ESAs) and iron therapy. Following concerns around ESA therapy, intravenous (IV) iron is being administered more and more worldwide. However, it is still unclear whether this approach is safe at very high doses or in the presence of very high ferritin levels. Some observational studies have shown a relationship between either high ferritin level or high iron dose and increased risk of death, cardiovascular events, hospitalization or infection. Others have not been able to confirm these findings. However, they suffer from indication biases. On the other hand, the majority of randomized clinical trials have only a very short follow-up (and thus drug exposure) and are inadequate to assess the mortality risk. None of them have tested the role of different iron doses on hard end points. With the lack of clear evidence coming from well-designed and large-scale studies, several data suggest that excessive iron therapy may be toxic in several aspects, ranging from iron overload to tissue damage from labile iron. A number of experimental and clinical data suggest that either excessive iron therapy or iron overload may be a possible culprit of atherogenesis. The process seems to be mediated by oxidative stress. Iron therapy should also be used cautiously in the presence of active infections, since iron is essential for bacterial growth. Recently, the European Medicines Agency officially raised concerns about rare hypersensitivity reactions following IV iron administration. The balance has been in favour of benefits. In several European countries, this has created a lot of confusion and somewhat slowed the run towards excessive use. Altogether, IV iron remains a mainstay of anaemia treatment in CKD patients. However, in our opinion, its excessive use should be avoided, especially in patients with high ferritin levels and when ESA agents are not contraindicated.

Project description:Stereotactic body radiation therapy (SBRT) also referred to as stereotactic ablative radiotherapy (SABR), is a technique which has emerged over the past two decades due to improvements in radiation technology. Unlike conventional external beam radiotherapy (cEBRT) which traditionally delivers radiation in small doses [approximately 2 Gray (Gy) per fraction] over several weeks, SBRT, typically delivered in one to eight fractions, is a technique whereby potentially ablative doses of radiotherapy (usually 7.5-20 Gy per fraction) can be delivered with steeper dose gradients and sub millimetre precision, minimising risk to surrounding normal tissues. The potential benefits of excellent tumor control with low toxicity has led to the increasing use of SBRT in a number of clinical situations. Due to compelling evidence, SBRT is now the treatment of choice for medically inoperable patients with peripherally located stage I non-small cell lung cancer (NSCLC). Controversy remains however as to its efficacy and safety for central or ultra-central lung tumors. The evidence base supporting the use of SBRT as a novel treatment for spinal metastases and oligometastases is rapidly expanding but challenges remain in these difficult patient populations. In an era where targeted therapy and improved systemic treatments for stage IV cancer have resulted in increased disease-free survival, and our knowledge of the oligometastatic state is ever expanding, using SBRT to treat metastatic disease and gain durable local control is increasingly desirable. Several randomized trials are currently underway and are sure to provide valuable information on the benefit and utility of SBRT across many tumor sites including early-stage NSCLC, spinal metastases and oligometastatic disease. Recognizing the evolving role of SBRT in clinical practice, this paper provides a critical review of recent developments in each of these areas particularly highlighting the challenges facing clinicians and discusses potential areas for future research.

Dataset Information

Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions.

Publications

Intravenous iron therapy in patients with chronic kidney disease: recent evidence and future directions.

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