Kidney Disease: Improving Global Outcomes (KDIGO)

Topic:

Target Parameters Iron Reserve

Guideline
Recommendation :

Evidence:

Notes:

CARI-Australia November 2003	1. - Prior to the commencement op epoetin therapy, adequate iron stores should be ensured. The following indices of iron stores should be maintained: serum ferritin > 100µg/L, transferrin saturation (TSAT) >20%, hypochromic red blood cells (RBC) < 10%. - Optimisation of epoetin may be obtained by achieving higher targets of iron reserve: serum ferritin 300-800 µg/L, TSAT 20-50%, hypochromic RBC <2.5%. 2. When serum ferritin>800µg/L or TSAT >50%, IV iron should be withheld for up to 3 months; when functional iron deficiency (see notes, right column), measure iron parameters before resuming iron with only half of the dose.	Guidelines: Part 1-Dialysis Guidelines. Biochemical and Haematological Targets. 7. Iron For rationale, each time read below the guidelines.	1. Level A Evidence. 2. Level B Evidence. - Absolute iron deficiency: ferritin < 100 µg/L, TSAT <20% and hypochromic RBC >20%. - Functional iron deficiency: ferritin >100 µg/L, TSAT <20% and hypochromic RBC > 20%. - On occasion an assessment of bone marrow should be obtained. No single test provides an adequate estimate of body iron stores. The percentage hypochromic RBC is currently the best parameter. Timing monitoring iron levels (Level C Evidence) - Stable pt, not on epoetin and with ferritin >100ng/mL and TSAT >20%: 3 monthly. - Initiating or increasing dose epoetin: monthly. - Stable pt with epoetin: 3 monthly. After parenteral iron administration wait 1week if iron dose <200mg, wait 2 weeks if iron dose>200mg (Level B Evidence)
CSN-Canada 1999	- Assess iron status by monitoring the mean corpuscular volume, transferrin saturation and serum ferritin over time. - In patients with TSAT<20% and/or ferritin <100ng/ml consider iron supplementation - Also in patients expected to develop iron deficiency as a result of hematopoiesis.	Guideline 2.3 Evaluation of Iron Status P 7 of 35 PDF pages Guideline 2.4 Treating iron deficiency. P 7 of 35 PDF pages	Evidence level IV. Evidence level IV. Evidence level III. Monitoring iron levels (Evidence Level IV) - Follow iron status every month when therapy to increase Hgb and at least every 3 months in stable patients. - TSAT and ferritin may be inaccurate if patients received IV iron within previous 2 weeks.
EBPG-Europe	- To achieve and maintain the target haemoglobin concentration iron should be administered to attain a serum ferritin >100µg/L and hypochromic RBC < 10% or TSAT >20% or reticulocyte Hb content (CHr)>29pg/cell. - To achieve these minimum levels aim for optimal levels of serum ferritin 200-500µg/L and hypochromic RBC <2.5% or TSAT 30-40% or CHr 35pg/cell. - The suggested upper limit of serum ferritin is 800µg/L	Revised EBPG for the Management of Anaemia in Patients with Chronic Renal Failure Part 2. Guideline II.2. What are the appropriate iron targets for anaemia treatment?	Evidence level B. Evidence level C. Excess parenteral iron is deposited in RES and unavailable to cause parenchymal damage.
KDOQI-US February 2004	-Iron status should be monitored by the percentage transferrin saturation and serum ferritin. -To achieve and maintain the target haemoglobin, iron should be administered to maintain a TSAT ≥20% and serum ferritin ≥100ng/ml. - CKD patients are unlikely to respond further when TSAT >50% and/or serum ferritin≥ 800ng/mL.	Guidelines for anaemia of chronic kidney disease. III Iron support. Guideline 5: Assessment of iron status. Guideline 6: Target iron level. P 125 of 204 PDF pages	Evidence Monitoring iron status (guideline 7) - During epoetin initiation and increasing dose, check TSAT and ferritin monthly (not receiving iron therapy), check 2-3 monthly when IV iron until target Hgb. (Opinion) - Stable Hgb every 3months (Opinion). - If not treated with epoetin and TSAT ≥ 20% and ferritin ≥100ng/ml, check every 3-6 months (Opinion) After parenteral administration wait 2 weeks if dose >1000mg (Evidence) and minimum 7 days if dose 200-500mg (Opinion)
UK-Guidelines August 2002	- A definition of adequate iron status is a serum ferritin > 100µg/L, hypochromic RBC < 10% and TSAT >20%. - A serum ferritin consistently >800g/L is suggestive of iron overload	7. Anaemia in patients with chronic renal failure P 125 of 204 PDF pages	Evidence level B. Evidence level B.