Nephrology

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David Charytan and other members of the Dialysis Advisory Group of the American Society of Nephrology have written a highly pertinent and timely review on the need for a robust evidence base for clinical practice in nephrology. In contrast to cardiology (and indeed most other hospital specialties!), nephrology lags behind, in terms of robust scientific evidence for much of its clinical practice, and this is the main focus of Charytan’s review.

A retrospective study has revealed that iron therapy is associated with a reduction in platelet count in patients with non-dialysis chronic kidney disease (ND-CKD) independent of erythropoiesis-stimulating agent (ESA) use. Iron therapy may therefore reduce the risk of relative thrombocytosis in this patient population.

Iron deficiency is a common disorder among patients with chronic kidney disease (CKD). A large-scale, epidemiological analysis conducted in 2009 suggests that the majority of patients with impaired kidney function (identified by reduced creatinine clearance) have low levels of iron, with approximately 58% of men and over 70% of women reaching the haematological definition of iron deficiency (See figure below)1. Rather than being a feature of later stages of disease only, iron deficiency has been reported from as early as CKD stage 31.

Intravenous ferric carboxymaltose and a higher ferritin target may delay or reduce the need for additional anaemia treatment compared with oral iron in chronic kidney disease (CKD). In addition, a greater proportion of patients achieve a faster haematological response and haemoglobin increase, researchers reveal.

Blood transfusion avoidance is an important goal in the management of patients with end-stage renal disease (ESRD). However, despite the increased use of agents to treat anaemia and iron deficiency over the last 15 years, the proportion of these patients receiving blood transfusions has doubled. 

A new study demonstrates that there is a high prevalence of anaemia in patients with advanced chronic kidney disease, which increases in the later stages of the disease. The authors suggest that control of anaemia may be achieved with moderate doses of erythropoietin stimulating agent (ESA) and iron therapy, as per current guidelines.

A single high dose of intravenous iron therapy has no significant effect on intact fibroblast growth factor 23 (FGF23) plasma levels for up to 7 days in normal and uraemic rats, new data indicate. These findings are of importance owing to the associations between increased mortality and FGF23 in patients with chronic kidney disease (CKD), who are often prescribed iron therapy.

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