With the new Medicare regs, the iron sat goal is now 30-40 and ferritin is 1,400. My corp is now suggesting patients get IV iron each month at clinic visits to keep these values up, thus Hgb should stay in range and less epo should be required. Previously, I did not need any IV iron for as long as a year. Can someone speak to the scenario of giving iron monthly as to whether it benefits patients or not?
Dear Jane, great question, but a very complex answer. Low iron levels are certainly well documented as a risk factor that also affects EPO response. Recent studies have questioned the levels of ferritin and iron, but in my own mind, I have not come across what I believe are definitive findings to date. Previous medical studies questioned the risks of high iron and ferritin levels and the effect on inflammation, infections and even come cancers. Since then, investigators have thought that the anemia itself was a more important factor than the iron levels or ferritin levels. I was at a prolonged discussion at the Annual Dialysis Conference in Seattle last years where a panel of experts truly didn’t agree on the best approach. As in all medical issues, discussing with your medical team the best response to your given situation is what we are left with. For myself, I am going to take the middle of the road approach, not too high, not too low since I don’t need any EPO to maintain HB over 11 until I am completely convinced of the best approach.
Here is a recent study that summarizes many of the issues, but I am not sure it answers all of them completely.
http://medind.nic.in/iav/t10/i3/iavt10i3p125.pdf
Perhaps Dr. Agar has a specific opinion on this issue, for myself, I am waiting for further clarification and preceding cautiously.
CMS expects dialysis clinics to follow the KDOQI Guidelines for many measures. The recommendations for transferrin saturation are >20% for HD and PD patients or a reticulocyte hemoglobin of >29 pg/cell. CMS also expects clinics to measure serum ferritin and the targets for for HD patients are >200 ng/ml and <500 ng/ml and/or evaluate the why it’s lower or higher. These levels along with multiple other criteria that clinics should be attempting to meet are on a “Cliff’s Notes” type document called the “Measures Assessment Tool” that is provided to ESRD surveyors who visit dialysis to monitor patient health and safety. The MAT is in a zip file named “Surveyor Laminates.”
http://www.cms.gov/GuidanceforLawsAndRegulations/05_Dialysis.asp
TY very much Dr. Laird and Beth for the info on how to look at the new iron regs. I am about to tackle the reading involved so I can discuss it with my neph at my next clinic visit. I can see why you have decided to take a middle of the road approach Dr. Laird.
I’m going to start a new thread on PTH as this is another situation that has changed quite a bit as far as how often labs are done.