In our program, patients must come to the unit to get iron. I place a buttonhole needle and the nurse gives me iron through the bh needle line. I have wondered if this method is safe for my fistula?

Our patients - and, to my knowledge, all other ~1000 home/nocturnals in Australia - all self-administer their 100 ml doses of iron polymatose at home (weekly, fortnightly, monthly or not at all) according to a sliding scale which is pegged to and depends on their Ferritin/Tsat bloods done every second month.

This is self-administered into the arterial line in 100 ml over 20 minutes at the start of dialysis … and although we are aware some patients just ‘whack it in’, this is against our clear recommendation.

When iron polymaltose is administered in our unit, it is given either by the patient or the dialysis nurse into the venous line at the end of dialysis as a bolus in 10 ml of N Saline.

Our patients are also trained to self-administer their own IV EPO and, on occasion and if required, their own IV antibiotics where an ongoing course of IV antibiotic is required.

As our patients use either the buttonhole (most) or ladder technique (some), it can be and is given into either their buttonhole or their ladder access needle.

When iron polymatlose is administered in our facility-based patients, it is given into the venous line at the end of dialysis as a bolus in 10 ml of N saline.

None have come to grief nor have had any identified issues or allergic responses. NB: their first ever dose of IV Fe++ is always given at the unit to ensure no adverse response. In >10 years experience with home nocturnal patients, we have yet to have an issue with this and also have had no indication of any AVF-related problems.

Although it should be noted that we know far too little about the things that impact on fistula care and saftey, I am unaware of any known ill effects of Fe++ on the AVF.

John Agar

First, I am glad to hear you say that giving iron through the accesss bhs is safe. I was concerned about that, because I rarely am given the rationale for procedures. I guard my fistula carefully and needed to know if this was a totally safe procedure.

Next, it is interesting to hear you say that Ferritin/Tsat bloods are done every other month there, because we do them monthly here along with Hgb. I have had an interesting experience in that since I started nocturnal almost 1 1/2 years ago, I have not needed iron one, single time. At first, I thought it might of been due to a benefit of doing nocturnal, but I have come to think that it is more due to my nurse’s anemia management skills.

I got a new nurse the same time I started nocturnal. She is gone now and another has taken her place and the first thing that happened was my Hgb and iron sat plunged, due I believe to failing to make the proper epo adjustment one month. I have had a number of iron loads at this point to get everything back in balance. But whereas Hgb has risen, iron sat. doesn’t want to stay up- it goes up and down. I have plenty of ferritin. My guess is the epo dose has been too high and it is eating up the available iron. But said all this to say that the success my previous nurse had with keeping my #s in range seemed to be due to the fact that we would take the labs more often so we could keep a better eye on things.

We would take them weekly if need be when the #s were either dropping too low or rising too high and that way my nurse shifted the epo dose 25% up or down more often thus keeping Hgb in range without the need for iron. In our system, Hgb must be kept between 10-12 or the unit won’t get paid. Most nurses I have had don’t seem to manage the shifts, but this nurse did well. We also must get our iron at the unit ( not all U.S. home programs, but our program). It is a total nusiance to make trips to the unit to get iron when if managed better it would not be necessary to do so so often or we could give it at home when necessary.

Unless there is something I don’t know about this balancing act, it sure seems like the previous nurse did a good job. Since she allowed me to do labs usually weekly to watch everything and adjust on time and that worked, I am clueless how you can do labs every other month over there and keep the balance, unless adjusting by a different scale still works on a 2 month basis. Patients here are always having problems with low Hgb and needing iron loads all the time. Again, unless there is something I don’t know, it sure seems like a case of poor anemia managment.

Your Aussie expressions are so humorous Dr. Agar. It was funny when you said some patients just “wack it in”. When my nurse gives me iron through my bh, she manually eases it in over a 10 min. period. In-center, when it was given through the machine, they would set the iron pump for varying lengths of time.

Can you say more on the rationale for why over there iron/epo is given either in the art or ven and at the onset of tx or at the end? Over here, I have heard where patients are using various different methods and timing. I was trained to give epo at the end of tx into the art. needle line followed by 10ccs of saline. And like I said, I go to the unit where the nurse gives iron in either one of my bhs.

Like that expression “come to grief” too lol.

Another lost reply! … Ah well … I will eventually learn!

I wrote a day or two back in reply but it didn’t upload and I lost the lot.

No, we dont find (nor, I must say, do I see why) such a degree of micro-management is needed. Your comment that … “we would take them weekly if need be when the #s were either dropping too low or rising too high and that way my nurse shifted the epo dose 25% up or down more often thus keeping Hgb in range without the need for iron” … makes little sense to me, given the half life of EPO (though I am not sure if you have been on alpha-epo, beta-epo or darbepoietin) … but whichever, I would have though, for most patients, a week (though it might be a long time in politics) is a short time in Hb/Epo adjustment. Obviously, if there are Hb or EPO dose wobbles in an individual, we would do bloods more often but weekly adjustment of EPO? … no, I’d say never - well, at least not in my service.

We just dont find ourselves (or our patients) getting into strife in stable patients - either home of facility-based - with 6 weekly bloods (facility) and 2 monthly bloods (in home NHD).

Why 6 and 8 weeks and not the same for both groups? … well, it just suits our (very local) chart review process to do it that way … and for no other sensible reason.

And … to be truthful, there probably isn’t much of a rationale for the Fe++ and/or EPO administration technique - well, not one that I am aware of that stacks up! I’d stick to what you are used to and with what works.

John Agar

I meant to say that at one point, at the tail end of the year, my iron sat finally dipped to 19 (my unit’s protocol is 20 although DOQI guidelines says 25). My nurse opted not to give iron as the other #s were up. And though we had watched everything very carefully until then, we let a month go by instead of our regular routine of watching weekly. It was then that the iron sat and Hgb got out of control and cascaded downward. Ever since that point, and an initial 5 session iron load plus more iron loads, have not been able to get these #'s up for almost 6 months now, and while my Hgb is up at last, my iron sat is still too low. I am clueless at how things went so well for an entire year and it has taken so long to build back up. For one thing, with nocturnal patients, do you find that it is the norm for nocturnal patients not to need iron for an entire year?

The reason I discussed with my nurse taking my labs weekly is because in-center patients get theirs taken weekly and though my epo dose fluctuated 1000-2000 when mine was taken weekly the years I was in-center, it was low and stable. At one time when I started doing SDD at home, things got so out of wack I was being given 10x the amount of epo I normally took, so that was a big red flag to me that something was seriously off. We got that under control by watching things weekly at that point. But then when I started nocturnal, that is when I did not need iron again for an entire year with Hgb being perfectly in range each month. Not sure what type of epo I am given, just that it is called Epotien sp? and is the most common type used here. And I do know what you mean about the half life of epo, yet adjusting it more frequently seems to be what has worked for me. The new nurse is having me do labs 2x/month now, but even that may not work as well. So like you said, I will continue with what worked since I don’t want the yo yo effect and I certainly don’t want to have to travel to the unit for iron every time I turn around. Just amazing though that labs are taken at 6 and eight week intervals there- maybe you Larrikin people don’t need it taken more often then that lol.