Clinical update: intravenous iron for anaemia Efficacy of IV iron compared to oral iron for increment of haemoglobin level in anemic chronic kidney disease patients on erythropoietin therapy. [Effectiveness of oral versus parenteral iron substitution in autologous blood donors]. Effects of early parenteral iron combined erythropoietin in preterm infants The effect of early recombinant erythropoietin and enteral iron supplementation on blood transfusion in preterm infants. Effect of intravenous iron supplementation on erythropoiesis in erythropoietin-treated premature infants. A comparison of oral and intravenous iron supplementation in preterm infants receiving recombinant erythropoietin. Phase III, randomized study of the effects of parenteral iron, oral iron, or no iron supplementation on the erythropoietic response to darbepoetin alfa for patients with chemotherapy-associated anemia. Effect of iron-supplemented total parenteral nutrition in patients with iron deficiency anemia. A Randomized, Controlled Trial of the Effects of Adding Vitamin B12 and Folate to Erythropoietin for the Treatment of Anemia of Prematurity Comparison of oral versus intravenous iron therapy in predialysis patients of chronic renal failure receiving recombinant human erythropoietin. [Evaluation of treatment results for anemia of prematurity treated with various doses of human recombinant erythropoietin]. WHO sponsored collaborative studies on nutritional anaemia in India. The effect of parenteral iron administration in the control of anaemia of pregnancy. Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data Clinical practice guidelines for evidence-based use of erythropoietic-stimulating agents. Efficacy and safety of intravenously administered iron sucrose with and without adjuvant recombinant human erythropoietin for the treatment of resistant iron-deficiency anemia during pregnancy. Perisurgical erythropoietin application in anemic patients with colorectal cancer: A double-blind randomized study.
For nearly half a century , parenteral iron has been considered dangerous and for use only in extreme situations and when oral iron was not tolerated . This proscription was based largely on poorly characterised and infrequent anaphylactoid reactions to the high-molecular-weight dextran preparation ( Imferon ) that for most of this time was the only product available . Moreover , when parenteral iron was necessary , the recommended approach was small intramuscular doses ( ≤100 mg ) , even after intravenous administration of the total iron defi cit as a single dose or as repetitive boluses was shown to be as safe and eff ective as the intramuscular route . This mindset persists despite the subsequent introduction of low-molecular-weight iron dextran and two iron salt preparations , ferric gluconate and iron saccharate ( the latter is also known as iron sucrose ) , all of which are associated with fewer serious adverse events than the high-molecular-weight dextran . The introduction of recombinant erythropoietin for dialysis patients was associated with the development , in some individuals , of functional iron defi ciency that limited effi cacy . Intravenous iron , unlike oral iron , improves erythropoietic response in dialysis patients , and is now routinely used . The discovery of the iron regulatory peptide , hepcidin , has improved our underst and ing of the anaemia of chronic infl ammatory states , including cancer . Hepcidin is upregulated in these conditions , result ing in increased synthesis by the liver . Hepcidin inhibits iron transport across cell membranes , which decreases the accessibility of storage iron and gastrointestinal absorption of dietary iron , leading to an increased frequency of iron-restricted erythropoiesis , especially during therapy with recombinant erythropoietin . The most frequent laboratory fi ndings during the anaemia of chronic infl ammation are hypoferraemia and a low percent transferrin saturation , although these fi ndings are not always present . The increasing use of recombinant erythropoietin to treat anaemia in patients with chronic diseases has exp and ed the population of patients with functional iron defi ciency and increased interest in safe rational approaches to parenteral iron therapy . There is mounting evidence that anaemic patients with cancer undergoing chemotherapy and receiving  recombinant erythropoietin respond better when parenteral iron is administered . This benefi t is independent of baseline iron variables , such as ferritin , low percentage transferrin saturation , and stainable marrow haemosiderin , leaving the clinician in need of laboratory variables to reliably detect iron-restricted erythropoiesis in patients with infl ammatory illnesses and to predict improvement of erythropoietic response to parenteral iron in the setting of infl ammatory illness . Two new laboratory measures look promising : percent hypochromic red blood cells and reticulocyte haemoglobin content . These tests are reliable and accurate correlates of functional iron defi ciency . Although these investigations are not yet widely available , their use will probably exp and and guide identifi cation of functional iron defi ciency and rational intervention with parenteral iron . Currently , four parenteral iron preparations are available ( table ) . No r and omised trials have compared the safety and effi cacy of any of these agents . The largest retrospective review of dialysis experience suggests that most serious adverse events have been associated with the high-molecular-weight iron dextrans ( Imferon , which is no longer available and the current preparation , Dexferrum ) and are rare ( < 1:200 000 ) with the low-molecular-weight iron dextran or the two iron salts ( fi gure ) . Adverse event rates might be somewhat higher in patients with infl ammatory diseases in which immune-mediated drug reactions  may be observed more commonly than in dialysis patients . Some of the adverse clinical experience with parenteral iron is due to inappropriate supportive care . Myalgias , when they include chest and back discomfort , are mistakenly described as anaphylaxis , prompting Low – molecular – weight iron dextran Iron saccharate Ferric gluconate High – molecular – weight iron INTRODUCTION Anemia is the most common finding in chronic kidney disease patients .  Iron supplements are commonly prescribed for these patients with or without erythropoietin therapy by means of oral and intravenous iron . Both oral and intravenous irons have their own advantage and disadvantage , and the efficacy is also different . The objective of the study is to analyze the efficacy of oral and intravenous iron in chronic kidney disease patients on erythropoietin therapy , an erythropoiesis stimulating agents for increment of haemoglobin . METHODS This is a prospect i ve study comparing intravenous iron to oral iron in chronic kidney disease patients who underwent maintenance hemodialysis at different centers and visited Kathm and u Medical College Teaching Hospital from April 2010 to April 2011 . Patients having a haemoglobin level of < 11 g/dl , transferrin saturation ( TSAT ) < 25 % , ferritin < 300ng/ml and who were on erythropoietin therapy were allocated alternately into two groups to receive oral iron ( iron fumarate ) or IV iron ( iv sucrose ) .  Haemoglobin was measured after 30 days of therapy . RESULTS A significant increase in haemoglobin levels was observed in both groups . But the mean haemoglobin increment was more in the IV iron group than in the oral iron group . Sixty percent 60 % of patients in the IV iron group had an increase in the haemoglobin level of more than 1gm/dl while only 20 % of the oral iron group had this increase . CONCLUSIONS Intravenous iron therapy is more effective in raising the hemoglobin level in hemodialysis dependent chronic kidney disease patients OBJECTIVE Is intravenous iron therapy as efficient as oral iron supplementation in patients undergoing autologous blood donation ? DESIGN Prospect i ve , r and omized study . PATIENTS AND SETTING 30 male and 30 female patients , separated into two groups were examined prior to total hip replacement . INTERVENTIONS Patients of group O were given 6 x 50 mg Fe2 + aspartate/day orally , and patients of group P were given 0.75 mg/kg BW complex-bound Fe3 + once a week by infusion . In both groups therapy was started two weeks prior to the first donation . The substitution was continued the following six weeks until surgery . Hemoglobin , ferritin plasma concentrations and reticulocytes were monitored . The appearance of unwanted side effects was studied by question naire . RESULTS Hb decreased significantly in both groups . A difference was seen in the reticulocyte count and in the ferritin levels . Here we found a significant increase in group P compared with group O. 40 % of the patients who took the iron orally complained about unwanted side effects such as obstipation and diarrhoea , whereas none of the patients of the parenteral group had any complaints . CONCLUSIONS Stimulation of the erythropoiesis appeared to be more efficient with intravenous iron therapy than with oral iron supplementation . The oral dose has in about 40 % unwanted side effects . For this reason a parenteral iron therapy can be considered , but one must be aware that in some cases dangerous anaphylactic reactions could appear Backgroud : The aim of the study was to evaluate the effect of early parenteral iron supplementation combined erythropoietin for prevention of anemia in preterm infants . Methods : In total , 96 preterm infants were r and omly assigned to 3 groups : a control group receiving st and ard parenteral nutrition ( group 1 : n = 31 ) , an iron-supplemented group ( group 2 : IS , n = 33 ) , and an iron-supplemented combined erythropoietin group ( group 3 : IS+EPO , n = 32 ) . The primary objective was to assess hemoglobin ( Hb ) levels . The secondary objectives included assessment of red blood cell counts ( RBC ) , mean cell volume ( MCV ) , serum iron , ferritin , percentages of reticulocyte ( RET ) , total iron binding capacity ( TIBC ) and oxidative stress , which was assessed by measuring plasma levels of malondialdehyde and superoxide dismutase at baseline and at 2 weeks . The blood routine indices including Hb , RBC , MCV , and percentages of RET were measured at corrected age of 1 and 3 months . Results : At 2 weeks of life , the percentages of reticulocyte in group 2 and group 3 were significantly higher than those in group 1 ( 2.1±0.4 , 2.5±0.3 , and 1.7±0.3 , respectively , P < 0.001 , P<0.001 ) , whereas TIBC were significantly lower than those in group 1 ( 36.7±4.6 , 36.0±4.7 , and 41.6 ± 5.2 respectively , P = 0.011 , P = 0.006 ) . There were no significant differences in RBC counts , the levels of hemoglobin , ferritin , malondialdehyde , and superoxide dismutase among the 3 groups at 2weeks of life . RBC , Hb , MCV , body weight , body length , and head circumference at a corrected age of 1 month did not differ among 3 groups . At corrected age of 3months , more infants in the control group had abnormal Hb and MCV levels ( Hb levels : 114.3 ± 21.3 , 123.7 ± 31.6 , and 125.1 ± 21.2 , P = 0.021 , P = 0.034 , respectively ; MCV : 74.1 ± 3.5 , 78.3 ± 4.7 and 79.1 ± 5.2 , P = 0.017 , P = 0.012 , respectively ) , whereas cases of oral iron , cases of breastfeeding , RBC , body weight , body length , and head circumference were not different among 3 groups . Conclusion : Early parenteral iron supplementation combined erythropoietin in preterm infants improved the percentages of reticulocyte , decreased total iron binding capacity , and improved the Hb and MCV levels at 3 months of age . Early parenteral iron supplementations with EPO were beneficial for the preterm infants Premature infants<1500 g were r and omly assigned to study and control groups . In the study group , 42 premature infants received recombinant human erythropoietin ( r-Hu EPO ) 750 U/kg per week subcutaneously from day 5 to 40 and enteral iron supplementation of 2 to 6 mg/kg/d beginning on day 14 provided that they were receiving at least 50 % energy intake orally . In the control group , 51 infants received the same dose of enteral iron supplementation beginning at the end of the fourth week . At the end of a 12-week monitoring period , r-Hu EPO combined with early enteral iron  reduced transfusion needs only in the subgroup<1000 g. r-Hu EPO and early iron treatment had no effect on the development of severe retinopathy of prematurity , intraventricular hemorrhage , necrotizing enterocolitis , and bronchopulmonary dysplasia . We suggest that r-Hu EPO combined with early enteral iron is both effective and safe in infants<1000 OBJECTIVE To test the efficacy and safety of combining intravenous iron in amounts approximating the in utero iron accretion rate and the postnatal iron loss with erythropoietin ( EPO ) in very low birth weight ( VLBW ) infants . METHODS A prospect i ve , controlled , r and omized , unmasked trial lasting 21 days was performed in 29 clinical ly stable VLBW infants < 31 weeks ' gestation and < 1300 g birth weight not treated with red blood cell transfusions during the study period . Mean ( + /- st and ard error of the mean ) age at study entry was 23 + /- 2.9 days . After a 3-day run-in baseline period in which all participants received oral supplements of 9 mg/kg/day of iron polymaltose complex ( IPC ) , participants were r and omized to receive 18 days of treatment with : 1 ) oral IPC alone ( oral iron group ) ; 2 ) 300 U of recombinant human EPO ( r-HuEPO ) kg/day and daily oral IPC ( EPO + oral iron group ) ; 3 ) 2 mg/kg/day of intravenous iron sucrose , r-HuEPO , and oral iron ( intravenous iron + EPO group ) . To assess efficacy of the 3 treatments , serial blood sample s were analyzed for hemoglobin ( Hb ) , hematocrit ( Hct ) , reticulocyte count , red blood cell indices and plasma levels of transferrin , transferrin receptor ( TfR ) , ferritin , and iron . Oxidant injury was assessed before and after treatment by plasma and urine levels of malondialdehyde ( MDA ) and o-tyrosine . RESULTS At the end of treatment , Hb , Hct , reticulocyte count , and plasma TfR were markedly higher in both of the EPO-treated groups , compared with the oral iron group . At study exit a trend toward increasing Hb and Hct levels and significantly higher reticulocyte counts were observed in the intravenous iron + EPO group , compared with the EPO + oral iron group . During treatment , plasma ferritin levels increased significantly in the intravenous iron + EPO group and decreased significantly in the other 2 groups . By the end of treatment , ferritin levels were significantly higher in the intravenous iron + EPO group compared with the other 2 groups . Although plasma and urine MDA or o-tyrosine did not differ among the 3 groups , plasma MDA was significantly greater in the subgroup of intravenous iron + EPO participants sample d at the end of the 2-hour parenteral iron infusion , compared with values observed immediately before and after parenteral iron-dosing . CONCLUSIONS In stable VLBW infants receiving EPO treatment , parenteral supplementation with 2 mg/kg/day of iron sucrose results in a small , but significant , augmentation of erythropoiesis beyond that of r-HuEPO and enteral iron alone . However , to reduce the potential adverse effects of parenteral iron/kg/day on increasing plasma ferritin levels and on causing oxidative injury , we suggest that the parenteral iron dose used should be reduced and /or the time of infusion extended to maintain a serum iron concentration below the total iron-binding capacity OBJECTIVE To determine whether intravenously administered iron supplements would improve the hematologic response to recombinant erythropoietin  in stable preterm infants . METHODS Forty-two preterm infants ( <33 weeks ' gestation , birth weight < 1500 gm , hematocrit < 38 % ) were treated with recombinant human erythropoietin ( Eprex ) , 600 U/kg per week , and r and omly assigned to receive either an oral preparation of ferrous lactate ( elemental iron , 12 mg/kg per day ) or an intravenous preparation of iron sucrose ( 6 mg/kg per week ) . RESULTS Hematocrits , reticulocyte counts , and transfusions were similar in the oral group ( OG ) and the intravenous group ( IVG ) . However , markedly higher serum ferritin concentrations were noted in the IVG ( p < 0.001 ) , and by completion of the study the arithmetic mean values were 265 + /- 127 microg/L versus 137 + /- 65 microg/L in the IVG and the OG , respectively . The numbers of hypochromic erythrocytes increased in both groups during the study but were significantly higher in the OG ( p = 0.04 ) . Mean daily weight gain in the IVG ( 27 + /- 6.4 gm/day ) was greater than in the OG ( 22.9 + /- 4.78 gm/day ; p = 0.04 ) . CONCLUSIONS High doses of both orally administered iron and intravenously administered iron sucrose appear to supply sufficient iron for erythropoiesis in stable infants . Storage iron may become depleted after oral supplementation . The intravenous preparation appears to be safe and maintains serum ferritin concentrations , and it may be indicated for patients with low ferritin levels and for those not established on enteral feedings PURPOSE Functional iron deficiency may impair response to erythropoiesis-stimulating agents ( ESAs ) in iron-replete patients with chemotherapy-associated anemia ( CAA ) . This study evaluated whether coadministration of parenteral iron improves ESA efficacy in patients with CAA . PATIENTS AND METHODS This prospect i ve , multicenter , r and omized trial enrolled 502 patients with hemoglobin ( Hb ) less than 11 g/dL who were undergoing chemotherapy for nonmyeloid malignancies . All patients received darbepoetin alfa once every 3 weeks and were r and omly assigned to receive either ferric gluconate 187.5 mg intravenously ( IV ) every 3 weeks , oral daily ferrous sulfate 325 mg , or oral placebo for 16 weeks . RESULTS There was no difference in the erythropoietic response rate ( ie , proportion of patients achieving Hb ≥ 12 g/dL or Hb increase ≥ 2 g/dL from baseline ) : 69.5 % ( 95 % CI , 61.9 % to 76.5 % ) of IV iron-treated patients achieved an erythropoietic response compared with 66.9 % ( 95 % CI , 59.1 % to 74.0 % ) who received oral iron and 65.0 % ( 95 % CI , 57.2 % to 72.3 % ) who received oral placebo ( P = .75 ) . There were also no differences in the proportion of patients requiring red cell transfusions , changes in quality of life , or the dose of darbepoetin administered . Adverse events ( AEs ) tended to be more common in the IV iron arm : grade 3 or higher AEs occurred in 54 % ( 95 % CI , 46 % to 61 % ) of patients receiving IV iron compared with 44 % ( 95 % CI , 36 % to 52 % ) who received oral iron and 46 % ( 95 % CI , 38 % to 54 % ) who received oral placebo ( P = .16 ) . CONCLUSION In patients with CAA , addition of IV ferric gluconate to darbepoetin failed to provide additional benefit compared with oral iron or oral placebo Iron deficiency anemia is common among hospitalized patients , and blood losses from diagnostic phlebotomy increase the likelihood of a negative iron balance . The role for iron supplementation of total parenteral nutrition ( TPN ) in these patients is unclear . Twenty-three patients with iron deficiency anemia were identified . Twelve patients were r and omized to receive TPN without iron ( group 1 ) and 11 received TPN supplemented with 10 mg of iron as iron dextran daily ( group 2 ) . Both groups were matched for age , serum iron studies , red cell indices , and hemogram . After a 7-d period , the mean serum iron in group 2 increased from 10 to 26 micrograms/dL , with an increased transferrin saturation from 7.3 to 15.3 % ( each , p < 0.05 ) . No changes in total iron binding capacity , ferritin , reticulocyte count , hemoglobin , hematocrit , or mean corpuscular volume were observed in the two groups . The incidence of infectious complications was not different between both groups . We conclude that iron supplementation of TPN appears safe and is effective in increasing serum iron levels . The use of iron-supplemented short-term TPN needs to be further studied given no change in red cell indices , hemoglobin , hematocrit , or transfusion requirement BACKGROUND . Premature infants , especially those with birth weights of < 1500 g , often suffer from anemia of prematurity and associated problems . Erythropoietin therapy is a safe effective way to prevent and to treat anemia of prematurity . We hypothesized that combined administration of vitamin B12 and folate with erythropoietin and iron would enhance erythropoietin-induced erythropoiesis . METHODS . In a r and omized , controlled trial , 64 premature infants ( birth weight : 801–1300 g ) receiving erythropoietin and iron supplementation  were assigned r and omly to receive either vitamin B12 ( 3 μg/kg per day ) and folate ( 100 μg/kg per day ) ( treatment group ) or a lower dose of folate ( 60 μg/kg per day ) ( control group ) . RESULTS . During the 4-week observation period , vitamin B12 and folate  enhanced erythropoietin-induced erythropoiesis significantly , as indicated by a 10 % increase in red blood cell counts , compared with folate alone . Hemoglobin and hematocrit levels remained stable in the treatment group , whereas they decreased in the control group  . Vitamin B12 levels in the treatment group increased over baseline and control values , whereas red blood cell folate levels were comparable between the groups . Subsequent analysis showed slight nonsignificant differences in baseline red blood cell count , hemoglobin level , hematocrit level , and mean corpuscular volume values , which must be addressed as a limitation . CONCLUSIONS . With the limitation of a slight imbalance in baseline data between the study groups , combined therapy with vitamin B12 , folate , erythropoietin , and orally and intravenously administered iron seemed more effective in stimulating erythropoiesis among premature infants , compared with erythropoietin , iron , and low-dose folate alone . Additional trials are necessary to confirm these data OBJECTIVES To compare oral versus intravenous iron in pre-dialysis patients of chronic renal failure ( CRF ) receiving recombinant human erythropoietin ( rHuEPO ) . METHODS The study was undertaken in 40 adult patients of chronic renal failure . The patients were r and omly divided into two groups A and B of 20 patients each . Group A patients were given oral iron and group B patients were given intravenous iron . All patients in both groups were given recombinant human erythropoietin 2000 IU twice weekly subcutaneously . The study was carried for up to three months . Patients were monitored every month for renal parameters and haematological parameters which included haemoglobin , reticulocyte count and packed cell volume . Ferrokinetic studies were done at baseline and at three months . RESULTS It was observed that haematological parameters showed significant statistical improvement in the intravenous iron group as compared to group A ( oral iron group ) . The ferrokinetic studies revealed that serum iron , serum ferritin and transferrin saturation , decreased significantly in oral iron group , whereas significant increase was seen in group B ( intravenous iron group ) . None of the patients developed any adverse effects because of erythropoietin or iron therapy . CONCLUSIONS Concomitant use of intravenous iron is better than oral iron in CRF patients treated with rHuEPO . The intravenous route of iron administration may be a preferred route along with rHuEPO therapy , more so in the Indian context where prevalence of iron deficiency anaemia is fairly high We evaluated the results of administering recombinant human erythropoietin ( rHuEPO ) and iron in 19 r and omly selected premature infants , who had no infections , did receive oxygen support or aminophylline .  rHuEPO was administered intravenously from days to 37 ( biweekly ) in a dose of 100 U/kg ( group I ) or 400 U/kg ( group II ) . Also , infants in both groups were supplemented with 10 mg/kg/week of iron intravenously . Seven of 19 infants did not receive either rHuEPO or iron ( group III ) . Infants of all groups had similar birth weights , gestational age and hematocrit , RBC count as well as total and fetal hemoglobin concentrations in blood obtained within the first hour of life . However , infants treated with 400 U/kg of rHuEPO required a significantly ( p < 0.04 ) lower volume of packed erythrocytes in comparison to untreated infants , both between days 7 and 37 of life ( 18.6 ml vs 46.8 ml ; p < 0.04 ) and between day 7 of life and the day of discharge ( 35.8 ml vs 94.2 ml ; p < 0.04 ) . No difference in neutrophil count , fetal hemoglobin concentration and no toxicity were observed in infants treated with rHuEPO in comparison to untreated prematures 1 . The relative efficacy of oral and parenteral iron administration in the prophylaxis and treatment of Fe-deficiency anaemia of pregnancy has been studied . 2 . Intravenous administration of Fe by total dose infusion of Fe dextran was not superior to oral Fe 120 mg/d , 6 d/week for 10 - 12 weeks . 3 . Intramuscular Fe dextran , 100 mg twice per week for 10 - 12 weeks , produced a significantly greater rise in mean haemoglobin concentration than oral Fe therapy . 4 . The superiority of intramuscular Fe as compared with intravenous Fe is probably related to the different h and ling of the Fe dextran by the reticulo-endothelial system . 5 . In spite of the better response to intramuscular Fe dextran , it is not recommended for public health practice because of the risks associated with its use and the much higher cost of the preparation and its delivery Introduction An important percentage of patients affected by hip fracture require the administration of allogenic blood transfusion ( ABT ) to avoid the risks of perioperative acute anaemia . However , concerns about ABT risks have led to the search for alternatives , especially in elective orthopaedic surgery . Material s and methods We have prospect ively investigated the effect of preoperative intravenous 200–300 mg ( group 2 ; n=20 ) iron sucrose on ABT requirements and postoperative morbid-mortality in patients undergoing surgery for displaced subcapital hip fracture ( DSHF ) repair . A previous series of 57 DSHF patients served as the control group ( group 1 ) . All patients were older than 65 years , were operated on the 3rd day after admission to the hospital , by the same medical team , and using the same implant . Age , gender , ASA classification , surgical procedure , perioperative haemoglobin , requirements for ABT , postoperative infection , length of hospital stay ( LOS ) and 30-day mortality rate were examined . Results No adverse reactions to the iron administration were observed . The iron group had a lower transfusion rate ( 15 % vs 36.8 % ) , lower transfusion index ( 0.26 vs 0.77 units per patient ) , lower 30d mortality rate ( 0 vs 19.3 % ) , shorter LOS ( 11.9 vs 14.1 days ) , as well as a trend to a lower postoperative infection rate ( 15 % vs 33 % ) . Conclusion Preoperative parenteral iron administration could be a safe and effective way to reduce the ABT requirements in DSHF patients . This reduction in the ABT requirements is accompanied by a reduction in the morbid-mortality rate and LOS . A large , r and omised , controlled trial to confirm these results is warranted BACKGROUND In patients with chronic kidney disease ( CKD ) , anemia is associated with left ventricular hypertrophy and adverse cardiovascular and clinical outcomes . Moreover , anemia is associated with a reduction in quality of life , particularly when the hemoglobin level drops below 100 g/l . 1 Thus , the goal of treating anemia in iron-replete patients with erythropoietic-stimulating agents ( ESAs ) is to reduce the likelihood of cardiovascular events , improve patients ’ survival , and improve patients ’ quality of life while minimizing any deleterious effects of the drug . Given that ESAs increase blood pressure and have other potential side effects , it is also important to assess whether the quantity of the ESA used might contribute to adverse events such as more rapid deterioration of kidney function , earlier requirement for dialysis , and vascular access failure . It is acknowledged that , if left untreated , patients with severe anemia may require blood transfusions , which have associated risks and costs , and possible implication s for patients awaiting a kidney transplant . In light of this , in most developed countries , the question for CKD patients with significant anemia has often not been whether to use ESAs , but when to use them and what target hemoglobin level to aim for . 2 The earliest anemia correction studies in nondialysischronic kidney disease ( ND-CKD ) and hemodialysis-chronic kidney disease ( HD-CKD ) patients compared the use of erythropoietin a with placebo . 3–5 Most early studies were not design ed and powered to examine clinical outcomes other than quality of life , and no differences were apparent in such other outcomes . Several of the studies showed improvements in quality of life compared with placebo . 3–5 Subsequent r and omized control trials ( RCTs ) have tended to examine the impact of using ESAs to achieve different target hemoglobin level ranges on surrogate endpoints , such as left ventricular ( LV ) mass , where patients with the lower hemoglobin target would be less likely to require the use of an ESA or would require lower doses to maintain the prespecified lower target hemoglobin . Two RCTs 6,7 in HDCKD patients compared with the use of ESAs to achieve intermediate hemoglobin and high hemoglobin targets . Although both studies showed no difference in progression of LV mass , the higher target hemoglobin led to improved quality of life in some of the domains , but the size of OBJECTIVE This study was undertaken to determine the efficacy and safety of intravenously administered iron sucrose with versus without adjuvant recombinant human erythropoietin in the treatment of gestational iron-deficiency anemia resistant to therapy with orally administered iron alone . STUDY DESIGN Forty patients with gestational iron-deficiency anemia were r and omly assigned to receive intravenously iron sucrose plus recombinant human erythropoietin or iron sucrose alone twice weekly . Target hemoglobin value was 11.0 g/dL. Efficacy measures were reticulocyte count , increase in hematocrit , and time to target hemoglobin level ( treatment duration in weeks and need for continued therapy after 4 weeks ) . RESULTS Both regimens were effective , but with adjuvant recombinant human erythropoietin the reticulocyte counts were higher from day 4 ( P<.01 ) , increases in hematocrit were greater from day 11 ( P < .01 ) , and the median duration of therapy was shorter ( 18 vs 25 days ) , with more patients reaching the target hemoglobin level by 4 weeks of treatment ( n = 19 vs. n = 15 ) . The groups did not differ with respect to maternal-fetal safety parameters . CONCLUSION Adjuvant recombinant human erythropoietin safely enhanced the efficacy of iron sucrose in the treatment of gestational iron-deficiency anemia resistant to orally administered iron alone BACKGROUND Blood transfusions are associated with higher postoperative morbidity and tumor recurrence rates in colorectal cancer surgery , To reduce the need for transfusions in patients with tumor-induced anemia who are not suitable for autologous blood donation , it was tested whether perisurgical erythropoietin application would be able to stimulate hematopoiesis adequately . METHODS In a double-blind r and omized study 150 IU/kg body weight erythropoietin was given subcutaneously every 2 days beginning 10 days before operation and continuing until postoperative day 2 . Twenty patients were r and omized into the erythropoietin group with three observed dropouts and 10 patients into the placebo group . RESULTS In the erythropoietin group two episodes of hypertension and one deep venous thrombosis were observed . Preoperative hemoglobin response in the erythropoietin group ( p = 0.069 ) was paralleled by a highly significant reticulocyte increase ( p = 0.0004 ) . However , frequency of blood transfusion was not different between both study groups ( erythropoietin , 1.82 + /- 0.80 units/ patient ; placebo , 1.80 + /- 0.97 units/patient ) . If iron availability was analyzed , a strong correlation between ferritin blood levels and transferrin iron saturation with hemoglobin response was observed in regression analysis ( p < 0.001 ) . CONCLUSIONS These results indicate that hematopoiesis in anemic patients with colorectal cancer can be stimulated by erythropoietin ; however , clinical efficacy is to be expected only in selected patients with high iron availability , which calls for further studies combining erythropoietin and parenteral iron application
High-dose parenteral iron does not seem to be associated with higher risk of infection , all-cause mortality , increased hospitalization or increased cardiovascular events on analysis of RCTs .
Observational studies show increased risk for all-cause mortality , infections and hospitalizations that were not statistically significant and were associated with significant heterogeneity
Parental iron is used to optimize hemoglobin and enhance erythropoiesis in end-stage renal disease along with erythropoietin-stimulating agents .
Safety of iron has been debated extensively and there is no definite evidence whether parenteral iron increases the risk of infections and mortality .
We performed this meta- analysis to evaluate the incidence of infectious complications , hospitalizations and mortality with use of parenteral iron .