Heard about the new guidelines for iron/epo. Can someone tell me the rationale behind how the high level for ferritin is now 1200, when previously it was 800… 1200 is not considered iron overload?
The C-TEPs proposed Iron guidelines but they are not new guidelines, they are not in force and if they are in use it is at the unit’s discretion.
I see, thanks. There must be some reason why my corp. has so readily gone with the proposed guidelines. For now, I just want to know if someone can answer how a Ferritin of 1,200 can be considered safe.
The issue of ferritin and iron deficiency is quite complex and evolving in our understanding. It is far from a settled issue at all at present. The guidelines you are discussing comes from the studies showing continued iron supplementation improves anemia and lessens the amount of EPO needed even with increasing levels of ferritin.
On the other hand, we have had many studies showing elevated ferritin to be a surrogate marker of worsening outcomes making the issue of elevated ferritin and iron supplementation quite an unsettled business altogether.
Iron is also a pro-stimulant of inflammation in the body which is in part one of the reasons that the ferritin is elevated in the first place. Ferritin is involved in what is called the acute phase reactions of inflammation. This is where the use of ferritin for a marker of iron overload is mitigated by the factor of inflammation. By itself, it is difficult to state what an elevated ferritin means without taking into account Hb levels as well as the other iron markers in conjunction with the patient’s clinical status.
My personal take for my own anemia management is to maximize my hemoglobin and iron levels and minimize my ferritin levels at the same time. I went to the dentist a year ago, one of my least favorite tasks. I had several fillings over 40 years old that had to be replaced, but when I did, my ferritin levels dropped. Inflammation is one of the leading causes of making it elevated completely unrelated to the iron issue.
I would simply recommend to stay tuned since the jury is still out on this issue. Read up on the issues and discuss them with your health care team. This is just one of many unsettled issues in dialysis care without a clear and consistent recommendation at present. Many experts argue for lowering ferritin stopping supplementation of iron at preset levels some argue to ignore ferritin and continue the iron supplementation. What is the right answer, I can’t say for sure at present.
Thank you for the excellent overview of this issue. How do you maximize your Hgb and iron levels while minimizing your ferritin levels other than the one example you gave?
I did not need IV iron for an entire year and would of not needed it even longer had we not gotten slack in managing the epo dose for a short period- that’s all it takes. With the proposed guidelines that my corp has decided to follow now, it would mean giving IV iron to get iron sat up even higher than it is now, thus also increasing ferritin. Not sure how it affects the other iron numbers. It seems like it would mean getting IV iron when I don’t need it since I am on a bare minimum dose of epo on nocturnal txs. This is what I am concerned about since hearing two different things this week. My nurse said they are changing the protocol in order to better manage those patients who are taking excessive dosages of epo. And another person told me that now that there is no longer an incentive for units to profit off of epo, they are going to this method to bring down their epo costs as they will now only get paid 50% as much as before per patient.
Dear Jane,
That is actually a little bit of a complex one. I noted that even dialysis related anemia has several factors, not just EPO and iron. In such, exercise in a fairly old study before EPO showed improvement and reduction of blood transfusions. Vit D likewise can increase the Hb by a point or so with supplementation. Lastly, IV iron has an immunogenic reaction increasing ferritin through inflammation. I haven’t had any EPO for over 3 years and no IV iron for 2 years, but I am drifting down slowly. Right now I am trying a course of oral iron combined with about 24 hours total dialysis each week which also increases Hb levels.
As far as the financial incentive issue with EPO, it is well documented that American nephrologists abused the dosing of EPO for profit making for decades and that is what has prompted the bundle. Knowing not only the advantages but the disadvantages of EPO, this is probably a good thing. People who like the improved quality of life with higher Hb from EPO must also take into account the increased risk of clotted access, MI, Stroke and a very real cancer risk especially in prior cancer patients.
Adding all of that together, I am working hard on all of the alternatives as long as I can.
I used oral iron and it was very effective for me at first. I liked the product I was using as there were no side effects. But then at a certain point I didn’t seem to be absorbing it. I couldn’t figure out at the time what was happening so I had to go back to IV iron. I am thinking of trying oral iron again as I hate having to come to the unit to get IV iron by placing a needle and getting it through my fistula. I wish I could give it at home through a drip. That would be my first choice.
Can you tell me what exactly are the effects of inflammation for us as dialysis patients?
[QUOTE=Jane;20255]I used oral iron and it was very effective for me at first. I liked the product I was using as there were no side effects. But then at a certain point I didn’t seem to be absorbing it. I couldn’t figure out at the time what was happening so I had to go back to IV iron. I am thinking of trying oral iron again as I hate having to come to the unit to get IV iron by placing a needle and getting it through my fistula. I wish I could give it at home through a drip. That would be my first choice.
Can you tell me what exactly are the effects of inflammation for us as dialysis patients?[/QUOTE]
Dear Jane, the entire issue of malnutrion/inflammation is once again quite complex but the basic aspect over rides many of the traditional cardiovascular risk factors seen in the general population. Here is a recent review on the issue:
If you take a look at epidemiology, elevated cholesterol most likely is still important in dialysis patients, but is hidden away in the entire malnutrition/inflammation complex. I still take my statin even the studies on statins and dialysis patients have been negative to date. I suspect that in the future, there may be components of the malnutrition/inflammation complex better understood which mitigate the effectiveness of statins and if taken into account, we may actually find a benefit for statins after all. Just speculation on my part at this time, but I will keep my statin nevertheless since it lowers my total chol by more than 100 points.