What is it about?

Critics of intravenous (IV) iron have pointed to indirect evidence that iron could cause infections, increase heart attacks, and death. A major trial giving large doses of IV iron to dialysis patients show it is actually safer than lower doses of iron, and does not increase infections. Higher doses of IV iron actually protect against heart complications and death.

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Why is it important?

IV iron is relatively inexpensive and reduces the use of Epoetin (or other erythropoiesis stimulating agents (ESA’s). IV iron is essentially ESA’s competitor. The ESA companies for years promoted IV iron as unsafe. Use of IV iron actually saves money by reducing ESA use. ESA’s have been shown to increase the risk of cardiac events, strokes, and death in previous major trials. More IV iron and less ESA is safer for dialysis patients. Similarly, heart failure (HF) is a huge health burden. Trials of IV iron versus placebo have shown iron improves HF patients’ stamina and quality of life, while reducing HF admissions and death. Why is IV iron good for dialysis and HF patients? It appears iron deficiency is more harmful than just mild anemia. In dialysis patients iron deficiency leads to overuse of ESA, which can increase thrombotic events like strokes, other cardiac problems, and even death. In HF, iron deficiency appears to impair increases in cardiac activity with exertion and skeletal muscle function. Iron deficiency limiting HF patients’ physical performance - they feel worse, cannot walk as far, and tend to have more hospitalizations. In both these populations - and likely others - Oral Iron is not effective. Oral iron is not well absorbed in these sick populations, while IV iron bypasses the GI tract and restores iron balance in the body.


In 2006, I helped alert the Nephrology community to the dangers of ESA’s. Trials completed in 2006 to 2009 confirmed the dangers of ESAs. I also pointed out the safety IV iron and its ESA-sparing effect. Over the past decade, randomized trials have now confirmed the benefits of IV iron. Iron deficiency is a more serious disorder than we generally regard it, especially in high risk groups like patients with chronic kidney disease and heart failure.

Daniel Coyne
Washington University in Saint Louis

Read the Original

This page is a summary of: The Value of Intravenous Iron: Beyond the Cave of Speculation, Journal of the American Society of Nephrology, April 2020, American Society of Nephrology,
DOI: 10.1681/asn.2019121340.
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