Perioperative Management of Perioperative Management of

Iron Deficiency Anemia Iron Deficiency Anemia

Perioperative Management of Perioperative Management of
Iron Deficiency Anemia Iron Deficiency Anemia
Moises Auron MD FAAP, FACP Moises Auron MD FAAP, FACP
HospitaI Medicine HospitaI Medicine
DiscIosure of FinanciaI ReIationships DiscIosure of FinanciaI ReIationships
Dr. Auron has Dr. Auron has no relationships no relationships with entities with entities
producing, marketing, re producing, marketing, re- -selling, or selling, or
distributing health care goods or services distributing health care goods or services
consumed by, or used on, patients. consumed by, or used on, patients.
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism
Normal body iron content ~ 3 to 4 g. Normal body iron content ~ 3 to 4 g.
- - Hemoglobin Hemoglobin ~ 2.5 g ~ 2.5 g
- - ron ron- -containing proteins (eg, myoglobin, containing proteins (eg, myoglobin,
cytochromes, catalase) ~ 400 mg cytochromes, catalase) ~ 400 mg
- - Transferrin Transferrin- -bound ~ 3 to 7 mg bound ~ 3 to 7 mg
- - Storage iron (ferritin; hemosiderin) Storage iron (ferritin; hemosiderin)
Storage varies according to gender Storage varies according to gender
- - Men ~ 1 g (liver, spleen, and bone marrow). Men ~ 1 g (liver, spleen, and bone marrow).
- - Women Women depends on physiologic factors depends on physiologic factors
(menses, pregnancies, deliveries, lactation, and (menses, pregnancies, deliveries, lactation, and
iron intake). iron intake).
Muoz M. Vox Sanguinis. 2008; 94: 172183
ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism ReguIation of Iron MetaboIism
rythropoiesis in CKD rythropoiesis in CKD rythropoiesis in CKD rythropoiesis in CKD
Kalantar-Zadeh K. Adv Chron Kid Dis. 2009; 16(2): 143-151.
HemogIobin HemogIobin HemogIobin HemogIobin
64.4 kd tetramer 64.4 kd tetramer 2 pairs of globin polypeptide chains 2 pairs of globin polypeptide chains
- - One pair alpha chains One pair alpha chains
- - One pair of non One pair of non- -alpha chains alpha chains
Heme group Heme group single protoporphyrin X bound to ferrous single protoporphyrin X bound to ferrous
(Fe2+) ion (Fe2+) ion linked covalently to each globin chain linked covalently to each globin chain
- - f iron is oxidized [ferric state (Fe3+)] f iron is oxidized [ferric state (Fe3+)] metHb metHb
Heme iron is linked covalently to histidine Heme iron is linked covalently to histidine
Oxygenation and deoxygenation Oxygenation and deoxygenation Hb conformational A Hb conformational A
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
Diagnostic indicators of IDA Diagnostic indicators of IDA Diagnostic indicators of IDA Diagnostic indicators of IDA
Soluble transferrin receptors(sTfRs) Soluble transferrin receptors(sTfRs)
sTfR sTfR ferritin index (sTfR ferritin index (sTfR F) F)
Zinc protoporphyrin/heme ratio (ZPP/H) Zinc protoporphyrin/heme ratio (ZPP/H)
Reticulocyte hemoglobin content (CHr) Reticulocyte hemoglobin content (CHr)
Selective endoscopy Selective endoscopy
Hepcidin Hepcidin
Clark SF. Curr Opin Gastroent. 2009; 25:122128.
%ests to assess Iron deficiency %ests to assess Iron deficiency %ests to assess Iron deficiency %ests to assess Iron deficiency
Muoz M. Vox Sanguinis. 2008; 94: 172183
$erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR) $erum %ransferrin Receptor (s%fR)
Skikne BS. Am J Hematol. 2008; 83:872875.
ndian J Pediatr 2010; 77 (2) : 179-183
Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio Serum TfR/Ferritin Ratio
s%fR | as body Fe stores | s%fR | as body Fe stores |
%fR/ferritin %fR/ferritin - - vaIuabIe measure of the extent of Fe vaIuabIe measure of the extent of Fe
deficiency deficiency
%fR/Iog ferritin %fR/Iog ferritin - - superior to the %fR/ferritin ratio, superior to the %fR/ferritin ratio,
s%fR or ferritin in correctIy distinguishing IDA vs. s%fR or ferritin in correctIy distinguishing IDA vs.
ACD vs. ACD from ACD + IDA (CMBI). ACD vs. ACD from ACD + IDA (CMBI).
s%fR had a sensitivity of 71% and specificity of s%fR had a sensitivity of 71% and specificity of
74% for correctIy identifying iron 74% for correctIy identifying iron- -depIeted marrow depIeted marrow
Ferritin which had a sensitivity of 25%, but Ferritin which had a sensitivity of 25%, but
specificity of 99%. specificity of 99%.
Skikne BS. Am J Hematol. 2008; 83:872875.
Means RT. Clin. Lab. Haem. 1999; 21:161167
Degree of Iron deficiency Degree of Iron deficiency Degree of Iron deficiency Degree of Iron deficiency
Gasche C, et al. nflamm Bowel Dis 2007;13:15451553
MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD MortaIity predictabiIity in CKD
Kalantar-Zadeh K. Adv Chron Kid Dis. 2009; 16(2): 143-151.
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
anzoni's formuIa anzoni's formuIa anzoni's formuIa anzoni's formuIa
Total Fe deficit (mg) = [Wt (kg) x Total Fe deficit (mg) = [Wt (kg) x (14 (14 - - actual Hb) x 0.24] + actual Hb) x 0.24] + 500 500
(iron depot) (iron depot)
- - Blood volume 70 ml/kg of BW ~7% of body weight Blood volume 70 ml/kg of BW ~7% of body weight
- - Fe content of Hb 0.34% Fe content of Hb 0.34%
- - Factor 0.24 = 0.0034 x 0.07 x 1000 (g to mg). Factor 0.24 = 0.0034 x 0.07 x 1000 (g to mg).
70 kg; Hb 9 g/dL ~ deficit of 1400 mg. 70 kg; Hb 9 g/dL ~ deficit of 1400 mg.
Underestimation of iron depot in males Underestimation of iron depot in males
- - ~ 700 ~ 700- -900 mg. 900 mg.
Muoz M, et al. World J Gastroenterol 2009; 15(37): 4666-4674
Ganzoni AM. ntravenous iron-dextran: therapeutic and experimental possibilities.
Schweiz Med Wochenschr. 1970;100: 301303.
CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit
Blood volume (dL) Blood volume (dL) = 65 (mL/kg) x body weight (kg) = 65 (mL/kg) x body weight (kg) 100 (mL/dL) 100 (mL/dL)
Hb deficit (g/dL) Hb deficit (g/dL) = 14.0 = 14.0 [patient Hb] [patient Hb]
Hb deficit (g) Hb deficit (g) = = Hb deficit (g/dL) Hb deficit (g/dL) x x Blood volume (dL) Blood volume (dL)
ron deficit (mg) ron deficit (mg) = = Hb deficit (g) Hb deficit (g) x 3.3 (mg Fe/g Hb) x 3.3 (mg Fe/g Hb)
Volume of parenteral Fe (mL) Volume of parenteral Fe (mL) = = ron deficit (mg) ron deficit (mg) C(mg/mL) C(mg/mL)
Schrier SL. Up To Date. Version 18.3
Hemoglobin iron deficit (mg) = BW x (14 Hemoglobin iron deficit (mg) = BW x (14 - - Hgb) x (2.145) Hgb) x (2.145)
Volume of product required (mL) = BW x (14 Volume of product required (mL) = BW x (14 - - Hgb) x (2.145) Hgb) x (2.145) C C
C = %he concentration of eIementaI iron: C = %he concentration of eIementaI iron:
Iron dextran: 50 mg/mL Iron dextran: 50 mg/mL
Iron sucrose: 20 mg/mL Iron sucrose: 20 mg/mL
Ferric gIuconate: 12.5 mg/mL Ferric gIuconate: 12.5 mg/mL
CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit CaIcuIation of Iron deficit
Schrier SL. Up To Date. Version 18.3
AIgorithm for IV Iron AIgorithm for IV Iron
repIacement repIacement
AIgorithm for IV Iron AIgorithm for IV Iron
repIacement repIacement
Muoz M. Vox Sanguinis. 2008; 94: 172183
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
hat about IM iron? hat about IM iron? hat about IM iron? hat about IM iron?
Painful Painful
Associated with gluteal sarcomas Associated with gluteal sarcomas
Permanent discoloration of the skin Permanent discoloration of the skin
No evidence of superiority over V No evidence of superiority over V
Auerbach M. Am J Hematol. 2008; 83: 580588
ParenteraI Iron ParenteraI Iron ParenteraI Iron ParenteraI Iron
Gasche C, et al. nflamm Bowel Dis 2007;13:15451553.
http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022180lbl.pdf
Name MoIecuIar AnaphyIaxis %est dose [Fe] Max
eight (kD) required (mg/mI) Dose
Dextran
- HM (Dexferrum) 265 Y Y 50 1g
- LM (Infed) 165 Y Y 50 1g
Fe gIuconate (FerrIecit) < 50 N N 12.5 125mg
Fe sucrose (Venofer) 30-100 N N 20 200mg
ther iron preparations ther iron preparations ther iron preparations ther iron preparations
Ferumoxytol Ferumoxytol (Feraheme ) (Feraheme )
- - semi semi- -synthetic carbohydrate synthetic carbohydrate- -coated coated
superparamagnetic iron oxide nanoparticle superparamagnetic iron oxide nanoparticle
- - safe and effective when given as a rapid intravenous safe and effective when given as a rapid intravenous
infusion of up to 510 mg (infusion rate: up to 30 infusion of up to 510 mg (infusion rate: up to 30
mg/second) in patients with CKD and ESRD mg/second) in patients with CKD and ESRD
Safety concerns were hypotension and/or hypersensitivity Safety concerns were hypotension and/or hypersensitivity
reactions (anaphylaxis and/or anaphylactoid reactions). reactions (anaphylaxis and/or anaphylactoid reactions).
May transiently affect the diagnostic ability of MR May transiently affect the diagnostic ability of MR
http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022180lbl.pdf
DifficuIt beginnings DifficuIt beginnings DifficuIt beginnings DifficuIt beginnings
Self limited arthralgias and myalgias ~ 50% Self limited arthralgias and myalgias ~ 50%
- - Only 1 in 87 patients had nonfatal anaphylaxis Only 1 in 87 patients had nonfatal anaphylaxis
- - Decreased with methylprednisolone (125 mg) Decreased with methylprednisolone (125 mg)
before and after infusion (1998) before and after infusion (1998)
- - No relationship with infusion rate No relationship with infusion rate
- - Lack of efficacy of ASA and diphenhydramine Lack of efficacy of ASA and diphenhydramine
Single case report in Lancet (1983) of meningismus Single case report in Lancet (1983) of meningismus
- - Patient with myalgia/arthralgia syndrome Patient with myalgia/arthralgia syndrome
Oral iron Oral iron - - inexpensive and effective if tolerated inexpensive and effective if tolerated
- - decreased interest in parenteral iron. decreased interest in parenteral iron.
Auerbach M. Am J Hematol. 2008; 83: 580588
%he evoIution of iron preparations %he evoIution of iron preparations %he evoIution of iron preparations %he evoIution of iron preparations
HMWD (DexFerrum) HMWD (DexFerrum) 11 11- -fold fold serious AE vs. LMWD (nFeD) serious AE vs. LMWD (nFeD)
- - Anaphylactic reactions Anaphylactic reactions
Non Non- -dextran preparations dextran preparations
- - Ferric gluconate Ferric gluconate
Patients with reactions Patients with reactions have no tryptase have no tryptase
125 mg V push over 5 125 mg V push over 5 10 min 10 min
- - ron sucrose ron sucrose
200 mg V push or 300 mg over 2 hr 200 mg V push or 300 mg over 2 hr
LMWD, ferric gluconate, and iron sucrose: LMWD, ferric gluconate, and iron sucrose: similar AE's similar AE's
- - Estimated incidence of <1:200,000. Estimated incidence of <1:200,000.
Auerbach M. Am J Hematol. 2008; 83: 580588
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD and ACD ron in CKD and ESRD and ACD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
Iron in $RD Iron in $RD Iron in $RD Iron in $RD
Eschbach (1987) Eschbach (1987) 1g V Fe dextran in dialysis patients failing 1g V Fe dextran in dialysis patients failing
to respond to EPO (standard dose of 50 U/kg 3 x wk) despite to respond to EPO (standard dose of 50 U/kg 3 x wk) despite
Ferritin > 500 ng/ ml. Ferritin > 500 ng/ ml.
Fishbane Fishbane V Fe: V Fe:
- - Decreased suboptimal response to EPO: 30 Decreased suboptimal response to EPO: 30 40% to 40% to < 10% < 10%
- - | dosing and duration of EPO | dosing and duration of EPO
- - Poor compliance and |absorption Poor compliance and |absorption avoid PO Fe avoid PO Fe
- - V Fe 1g V Fe 1g rapid improvement of erythropoiesis and rapid improvement of erythropoiesis and
replenishment of depleted stores. replenishment of depleted stores.
Administered over 10 doses. Administered over 10 doses.
Serious AE ~ 0.7% Serious AE ~ 0.7%
~ 0.3% ~ 0.3% - - acute chest and back pain without |BP, RR, acute chest and back pain without |BP, RR,
HR, wheezing, stridor, or periorbital edema HR, wheezing, stridor, or periorbital edema
Self limited reactions. Self limited reactions.
Auerbach M. Am J Hematol. 2008; 83: 580588
Iron and $RD Iron and $RD Iron and $RD Iron and $RD
Hoen et al. Hoen et al.
- - N = 998 hemodialysis patients N = 998 hemodialysis patients
- - No association of ferritin levels or V Fe No association of ferritin levels or V Fe
administered with infections. administered with infections.
Clin Nephrol. 2002 Jun;57(6):457-61.
IDA in Uremia IDA in Uremia IDA in Uremia IDA in Uremia
Bacterial overgrowth Bacterial overgrowth
G bleeding G bleeding
- - Platelet dysfunction Platelet dysfunction
- - Anti Anti- -platelets platelets
Frequent phlebotomy Frequent phlebotomy
Proteinuria Proteinuria
Fe utilization (ESA) Fe utilization (ESA)
MacDougall C. Curr Med Res & Opin. 2010; 26(2):473482.
| Dietary source | Dietary source
- - Anorexia Anorexia
- - Low protein diet Low protein diet
| G absorption | G absorption
- - Hepcidin Hepcidin
- - PO4 binders, Ca PO4 binders, Ca
2+ 2+
- - Achlorhydria Achlorhydria
- - Atrophic gastritis Atrophic gastritis
Iron in $RD Iron in $RD Iron in $RD Iron in $RD
NKF NKF- -KDOQ KDOQ
- - V iron in preference to p.o. iron V iron in preference to p.o. iron
- - Serum ferritin >100 ng/ mL Serum ferritin >100 ng/ mL
- - Hold Fe if Hold Fe if ferritin > 800 ng/mL ferritin > 800 ng/mL and and Tsat > 50% Tsat > 50%
- - V iron can be administered: V iron can be administered:
LMWD LMWD total infusion dose or repeated doses total infusion dose or repeated doses
Ferric gluconate or iron sucrose Ferric gluconate or iron sucrose repeated doses repeated doses
Auerbach M. Am J Hematol. 2008; 83: 580588
IV Iron in Non IV Iron in Non- -diaIysis CKD diaIysis CKD IV Iron in Non IV Iron in Non- -diaIysis CKD diaIysis CKD
MacDougall C. Curr Med Res & Opin. 2010; 26(2):473482.
Anemia of chronic disease Anemia of chronic disease Anemia of chronic disease Anemia of chronic disease
Disturbed iron homeostasis Disturbed iron homeostasis
- - | absorption and | Fe recycling from RES | absorption and | Fe recycling from RES
- - hypoferremia (low transferrin hypoferremia (low transferrin- -bound iron) bound iron)
BD BD
- - .V. Fe .V. Fe route of choice route of choice
Potential of worsening BD with P.O. Fe Potential of worsening BD with P.O. Fe
Auerbach M. Am J Hematol. 2008; 83: 580588
Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy Anemia of cancer and chemotherapy
Multiple studies of patients with different type of cancer Multiple studies of patients with different type of cancer
on chemoradiation or chemotherapy on ESA on chemoradiation or chemotherapy on ESA
- - Randomized to ESA alone, p.o. vs. i.v. ron Randomized to ESA alone, p.o. vs. i.v. ron
V iron V iron
- - ncrease in Hb > 2 g/dL ncrease in Hb > 2 g/dL
- - 45% decrease in allogenic blood transfusions 45% decrease in allogenic blood transfusions
- - reduces ESA failure reduces ESA failure
- - Oncology Oncology no difference in tumor outcomes vs. ESA no difference in tumor outcomes vs. ESA
Auerbach M. Am J Hematol. 2008; 83: 580588
Auerbach M. Am J Hematol. 2008; 83: 580588
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD ron in CKD and ESRD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
ParenteraI iron in surgery ParenteraI iron in surgery ParenteraI iron in surgery ParenteraI iron in surgery
Efficacy of V ron Efficacy of V ron
- - Major elective surgery (N = 84) Major elective surgery (N = 84)
33 CORS, 33 Gynecologic, 21 Ortho 33 CORS, 33 Gynecologic, 21 Ortho
- - V iron mean dose 1000 mg V iron mean dose 1000 mg ++ 440 mg 440 mg
Hb > 2.0 g/dl Hb > 2.0 g/dl
Resolved anemia ~ 58% of cases Resolved anemia ~ 58% of cases
No life No life- -threatening AE's threatening AE's
Oral vs. V ron Oral vs. V ron
- - Gynecologic surgery (N = 76; Hb <9.0 g/dl) Gynecologic surgery (N = 76; Hb <9.0 g/dl)
- - V Fe sucrose 3/wk vs. daily PO Fe succinylate V Fe sucrose 3/wk vs. daily PO Fe succinylate
Hb (3.0 vs. 0.8 g/dl; Hb (3.0 vs. 0.8 g/dl; p < 0.0001 p < 0.0001) )
Ferritin levels (170.1 vs. 4.1 microg/l; Ferritin levels (170.1 vs. 4.1 microg/l; P<0.0001 P<0.0001) )
Target Hb (76.7% vs. 11.5%; Target Hb (76.7% vs. 11.5%; p < 0.0001 p < 0.0001). ).
Muoz M. Med Clin (Barc). 2009 Mar 7;132(8):303-6.
Garca-Erce JA. Anemia 2009; 2: 17-27.
Kim YH. Acta Haematol. 2009;121(1):37-41.
IV Iron IV Iron IV Iron IV Iron
Orthopedic surgery Orthopedic surgery
- - Meta Meta- -analysis (N = 807) analysis (N = 807)
- - transfusion rate [ transfusion rate [RR: 0.60 RR: 0.60, 95% C: 0.50 , 95% C: 0.50- -0.72, P < 0.001] 0.72, P < 0.001]
- - infection rate [ infection rate [RR: 0.45 RR: 0.45, 95% C: 0.32 , 95% C: 0.32- -0.63, P < 0.001] 0.63, P < 0.001]
Colorectal surgery Colorectal surgery
- - 43 colorectal cancer patient 43 colorectal cancer patient
Transfusion index 4.0 vs. 1.3 unit/patient Transfusion index 4.0 vs. 1.3 unit/patient
V antibiotics (33% vs. 9%) V antibiotics (33% vs. 9%)
Garca-Erce JA. Anemia 2009; 2: 17-27.
Kim YH. Acta Haematol. 2009;121(1):37-41.
Muoz M. Semin Hematol. 2006; 43:S36-8
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD ron in CKD and ESRD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
PotentiaI negative effects of PotentiaI negative effects of
intravenous iron intravenous iron
PotentiaI negative effects of PotentiaI negative effects of
intravenous iron intravenous iron
Pro Pro- -oxidant oxidant - - might increase oxidative stress, might increase oxidative stress,
infections, mortality, tumor growth. infections, mortality, tumor growth.
- - p.o. ron p.o. ron - - worsening BD (Fenton reaction) worsening BD (Fenton reaction)
Non Non- -ESRD patients ESRD patients nephrotoxicity? nephrotoxicity?
- - Transient increase in induced proteinuria and Transient increase in induced proteinuria and
albuminuria with iron sucrose. albuminuria with iron sucrose.
- - Ferric gluconate showed significant increases in Ferric gluconate showed significant increases in
lipid peroxidation. lipid peroxidation.
Auerbach M. Am J Hematol. 2008; 83: 580588
Iron and infectious diseases Iron and infectious diseases Iron and infectious diseases Iron and infectious diseases
Weinberg ED. Emerg nfect Dis 1999;5:34652.
Body iron and disease Body iron and disease Body iron and disease Body iron and disease
Weinberg ED. Emerg nfect Dis 1999;5:34652.
Iron Adverse drug events Iron Adverse drug events Iron Adverse drug events Iron Adverse drug events
FDA (2001 FDA (2001 - - 2003) 2003)
- - 30 miIIion doses 30 miIIion doses
- - 11 deaths 11 deaths
- - 1141 totaI ADs 1141 totaI ADs
ron sucrose ron sucrose - - 0.6 per million doses 0.6 per million doses
Ferric gluconate Ferric gluconate - - 0.9 per million doses 0.9 per million doses
LMWD LMWD - - 3.3 per million doses 3.3 per million doses
HMWD HMWD - - 11.3 per million doses 11.3 per million doses
Chertow GM. Nephrol Dial Transplant. 2006;21(2):378-82.
utIine utIine utIine utIine
ron metabolism ron metabolism
Diagnosis of DA Diagnosis of DA
Calculation of ron deficit Calculation of ron deficit
ron preparations ron preparations
ron in CKD and ESRD ron in CKD and ESRD
ron in Surgery ron in Surgery
Adverse effects of parenteral iron Adverse effects of parenteral iron
CCF Preoperative ron replacement algorithm CCF Preoperative ron replacement algorithm
NATA (Network for Advancement of Transfusion Alternatives) NATA (Network for Advancement of Transfusion Alternatives)
- - 2 RCT 2 RCT
- - 6 Observational studies 6 Observational studies
Preoperative Fe therapy Preoperative Fe therapy | 2/3 | 2/3 Blood Transfusion Blood Transfusion
V ron: V ron: Ferritin < 100, Tsat < 20%, EBL > 1500 ml Ferritin < 100, Tsat < 20%, EBL > 1500 ml
Avoid V ron if Ferritin > 300 ng/ml and Tsat > 50%. Avoid V ron if Ferritin > 300 ng/ml and Tsat > 50%.
- - Acute infection. Acute infection.
Quality of Evidence is weak Quality of Evidence is weak
Recommend large RCT Recommend large RCT
Br J Anaesth 2008; 100: 599604.
Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion Cost of IV Iron vs. %ransfusion
Bieber EJ. OBG Management. 2010;22(2):28-38.
Silverstein SB. Am J Hematol. 2004; 76:7478.
Shander A. Transfusion. 2010:50:753-65
ron dextran ~ $377 per gram ron dextran ~ $377 per gram
ron gluconate ~ $688 per gram ron gluconate ~ $688 per gram
ron sucrose ~ $688 per gram ron sucrose ~ $688 per gram
Hemoglobin ~ $761 +/ Hemoglobin ~ $761 +/- - 294 per unit (~250 294 per unit (~250
mg) x 4 = mg) x 4 = $ 3044 per gram $ 3044 per gram
Recommended Preoperative IV Recommended Preoperative IV
Iron repIacement Iron repIacement
Recommended Preoperative IV Recommended Preoperative IV
Iron repIacement Iron repIacement
Venofer (Iron sucrose) 200 mg (10 mI) Venofer (Iron sucrose) 200 mg (10 mI)
administered over 10 minutes x 5 administered over 10 minutes x 5
doses. doses.
FerrIecit (Ferric gIuconate) 125 mg iv FerrIecit (Ferric gIuconate) 125 mg iv
over 1 hour x 8 doses (Inpatient). over 1 hour x 8 doses (Inpatient).