Editor’s Note: The changing of the economic guard for erythropoiesis-stimulating agents in 2011 has pushed many nephrologists and clinics to use less and push more iron. But do the high ferritin levels in the US suggest we have gone too far? Are there better ways to create a balance? We interviewed nephrologist Steven Fishbane, VP and Chief of Kidney Diseases and Hypertension at Hofstra Northwell Health, and Tommy Carter, founding partner and CEO of RenalSouth of Rome LLC and Renal Billing/ National Billing Associates Inc., to help us understand the clinical and the practical issues around iron management.

NN&I: Patient are getting more iron today then during the pre-ESRD payment bundle era. Do you have concerns about the subsequent increases in iron use and ferritin levels?

Steven Fishbane, MD: The very helpful DOPPS [Dialysis Outcomes and Practice Patterns Study] Practice Monitor shows that IV iron use has stabilized in the U.S. over the past four years. But that doesn’t change an essential fact: We, as a community of professionals, learned an important lesson about ESA safety. With IV iron, in contrast, we treat it like it is water in 70% of patients each month, but haven’t worked out whether it is a truly safe group of drugs.

NN&I: Has more efficient use of ESAs by having more patients getting higher doses of iron therapy — helped the bottom line for dialysis providers?

Read also: Trends in iron therapy
To maintain adequate delivery of iron to the erythroid marrow in the setting of ongoing blood loss from HD, most patients in the post-ESA era have required IV iron supplementation as oral iron is not sufficiently bioavailable to meet iron needs. More

Tommy Carter: I would not say “higher” doses of iron, but more “frequent” doses of iron have made increases of hemoglobin levels easier to achieve and maintain. With the use of Triferic and excellent anemia management by our clinical staff, ESA and IV iron usage has been reduced dramatically in the majority of our patients.

NN&I: Some, but not all, new ESAs—Mircera, for example, and Amgen’s already established Aranesp product— are longer titrating, allowing staff to give them once every two weeks, or longer. Does that make it more difficult to create a balanced ESA/iron prescription?

SB: I don’t think so. I love the fact that Mircera frees nurses to do what they are so great at: patient assessment and education. I also look forward to the possibility of oral HIF stabilizers, which would also free up the nurses to do direct patient care instead of injections.

NN&I: We do hear these longer titrating ESAs can save on nursing time. But what about reducing dosages? Are there cost savings for the clinic?

TC: There is definitely savings in nursing administration time and cost of disposable supplies. To say we are seeing a reduction in dose would not be a fair comparison, but we do have a significant reduction in the number of doses administered per month.

NN&I: What do you like about Triferic, and its delivery mechanism?

Read also: Interpreting tests of iron sufficiency in patients with ESRD: Inflammation, evidence, and recommendations
Accurate assessment of iron status is critical to prescribing treatments for anemia in chronic kidney disease and assessing the effectiveness of those treatments. More

SB: The slower administration and lower dose is more physiologic and easier for the body to manage through normal homeostatic mechanisms compared to IV iron. People typically eat 10-15 mg of iron per day over 24 hours. In contrast, IV iron therapy means you get 100 mg injected into the blood stream over 5 minutes. By casual inspection, patients look fine after rapid injections of 100 mg of IV iron. But what are the underlying effects?

The findings of the PIVOTAL study may be very important. In this four-year trial, some patients will be given high doses of iron, but not so much as to be considered unsafe. Another group will receive lower doses of iron, as per normal routine treatment, when their iron levels start getting too low. A third group will receive lower doses of iron only as per normal routine treatment when anemia symptoms appear.

TC: I like its simplicity of replacing the amount of iron that is lost during a dialysis treatment through the dialysate and delivered to the bone marrow without having to go through the liver. I see it as having the patients’ stolen goods (iron) delivered back to the rightful owner (patient) by a bullet train instead of a bus.