Iron deficiency in chronic kidney disease
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Iron deficiency anemia
Renal Insufficiency
Iron deficiency
Oral iron
Intravenous iron

How to Cite

Ariza-Garcia A, Cabeza Morales M, Arnedo Arteaga F, Salgado Montiel LG, Romero Rivera H, Bello Espinosa A, Maza Villadiego A. Iron deficiency in chronic kidney disease. Rev. Colomb. Nefrol. [Internet]. 2023 Oct. 25 [cited 2024 Jul. 18];10(1). Available from:


Background: Iron deficiency is a disorder frequently observed in patients with chronic kidney disease (CKD), especially in advanced stages. Its presence is associated with increased morbidity and mortality. Iron deficiency can be absolute or functional. Absolute deficiency refers to absent or reduced iron stores, while functional deficiency is defined by the presence of adequate iron stores but insufficient iron availability for incorporation into erythroid precursors. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood fi, impaired iron absorption, and chronic inflammation.

Purpose: With this narrative review, it is intended to present the details, pathophysiological aspects, diagnostic criteria and therapeutic options in patients diagnosed with chronic kidney disease with iron deficiency.

Methodology: A non-systematic review of the fi ronra was carried out, in the PubMed database, also including the most used international guidelines that address the issue fi ron deficiency in chronic kidney disease.

Results: A total of 30 bibliographical references were included. Iron deficiency can be absolute or relative. The absolute iron deficiency occurs with ferritin values < 100 mcg/l and transferrin saturation (TSAT) <20%, while functional deficiency is related to ferritin levels > 100 mcg/l but with a TSAT <20 % Treatment of absolute deficiency consists of oral or intravenous iron replacement. In a patient who is not yet receiving dialysis, a therapeutic trial with oral iron can be done, if there is no response, intravenous iron will be chosen. In patients receiving dialysis, the ideal measure is intravenous iron, preferably in preparations that allow high-dose schemes and low frequencies of administration. The goals proposed by the different guidelines present variations between 500 and 700 mcg/l d ferritin.

Conclusions: iron deficiency should be actively sought in patients with CKD, since its presence and lack of intervention leads to an increase in adverse outcomes. Iron therapy is the mainstay of treatment; the choice of the agent to be used depends on the individual characteristics of the patient and the availability of oral or intravenous iron preparations.
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Babitt JL, Eisenga MF, Haase VH, Kshirsagar AV, Levin A, Locatelli F, et al. Controversies in optimal anemia management: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int. 2021;99(6):1280-95.

Hsu CY, McCulloch CE, Curhan GC. Epidemiology of anemia associated with chronic renal insufficiency among adults in the United States: Results from the Third National Health and Nutrition Examination Survey. J Am Soc Nephrol. 2002;13(2):504-10.

Stauffer ME, Fan T. Prevalence of anemia in chronic kidney disease in the United States. PLoS One. 2014;9(1):2-5.

St Peter WL, Guo H, Kabadi S, Gilbertson DT, Peng Y, Pendergraft T, et al. Prevalence, treatment patterns, and healthcare resource utilization in Medicare and commercially insured non-dialysis-dependent chronic kidney disease patients with and without anemia in the United States. BMC Nephrol. 2018;19(1):1-11.

Portolés J, Martín L, Broseta JJ, Cases A. Anemia in Chronic Kidney Disease: From Pathophysiology and Current Treatments, to Future Agents. Front Med. 2021;8(mzo.):1-14.

van Swelm RP, Wetzels JF, Swinkels DW. The multifaceted role of iron in renal health and disease. Nat Rev Nephrol. 2020;16(2):77-98.

Besarab A, Drueke TB. The problem with transferrin saturation as an indicator of iron “sufficiency” in chronic kidney disease. Nephrol Dial Transplant. 2021;36(8):1377-83.

Eschbach JW, Cook JD, Finch CA. Iron absorption in chronic renal disease. Clin Sci. 1970;38(2):191-6.

Kooistra MP, Marx JJ. The absorption of iron is disturbed in recombinant human erythropoietin-treated peritoneal dialysis patients. Nephrol Dial Transplant. 1998;13(10):2578-82.

Descamps-Latscha B, Herbelin A, Nguyen AT, Roux-Lombard P, Zingraff J, Moynot A, et al. Balance between IL-1 beta, TNF-alpha, and their specific inhibitors in chronic renal failure and maintenance dialysis. Relationships with activation markers of T cells, B cells, and monocytes. J Immunol. 1995;154(2):882-92.

Macdougall IC, Bircher AJ, Eckardt KU, Obrador GT, Pollock CA, Stenvinkel P, et al. Iron management in chronic kidney disease: Conclusions from a “kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int. 2016;89(1):28-39.

Sociedad Española de Nefrología. Guía de Práctica Clínica sobre la detección y el manejo de la enfermedad renal crónica. España: Sociedad Española de Nefrología; 2016.

Pearce L. Chronic kidney disease assessment and management: updated guidance. Nurs Stand. 2021;36(12):11.

Macdougall IC, Bock AH, Carrera F, Eckardt KU, Gaillard C, Van Wyck D, et al. FIND-CKD: A randomized trial of intravenous ferric carboxymaltose versus oral iron in patients with chronic kidney disease and iron deficiency anaemia. Nephrol Dial Transplant. 2014;29(11):2075-84.

Olone EL, Hodson EM, Nistor I, Bolignano D, Webster AC, Craig JC. Parenteral versus oral iron therapy for adults and children with chronic kidney disease. Cochrane Database Syst Rev. 2019;(2):CD007857.

Shepshelovich D, Rozen-Zvi B, Avni T, Gafter U, Gafter-Gvili A. Intravenous Versus Oral Iron Supplementation for the Treatment of Anemia in CKD: An Updated Systematic Review and Meta-analysis. Am J Kidney Dis. 2016;68(5):677-90.

Wish JB, Anker SD, Butler J, Cases A, Stack AG, Macdougall IC. Iron Deficiency in CKD Without Concomitant Anemia. Kidney Int Reports. 2021 nov. 1;6(11):2752-62.

Cho ME, Hansen JL, Peters CB, Cheung AK, Greene T, Sauer BC. An increased mortality risk is associated with abnormal iron status in diabetic and non-diabetic Veterans with predialysis chronic kidney disease. Kidney Int. 2019 sept. 1;96(3):750-60.

Cho ME, Hansen JL, Sauer BC, Cheung AK, Agarwal A, Greene T. Heart Failure Hospitalization Risk associated with Iron Status in Veterans with CKD. Clin J Am Soc Nephrol. 2021;16(4):522-31.

Ponikowski P, Kirwan BA, Anker SD, McDonagh T, Dorobantu M, Drozdz J, et al. Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial. Lancet (Londres). 2020 dic. 12;396(10266):1895-904.

Anker SD, Kirwan BA, van Veldhuisen DJ, Filippatos G, Comin-Colet J, Ruschitzka F, et al. Effects of ferric carboxymaltose on hospitalisations and mortality rates in iron-deficient heart failure patients: an individual patient data meta-analysis. Eur J Heart Fail. 2018 en. 1;20(1):125-33.

Anker SD, Comin Colet J, Filippatos G, Willenheimer R, Dickstein K, Drexler H, et al. Ferric Carboxymaltose in Patients with Heart Failure and Iron Deficiency. N Engl J Med. 2009 dic. 17;361(25):2436-48.

Gutiérrez OM. Treatment of Iron Deficiency Anemia in CKD and End-Stage Kidney Disease. Kidney Int Reports. 2021;6(9):2261-9.

Tolkien Z, Stecher L, Mander AP, Pereira DI, Powell JJ. Ferrous Sulfate Supplementation Causes Significant Gastrointestinal Side-Effects in Adults: A Systematic Review and Meta-Analysis. PLoS ONE. 2015;10(2):e0117383.

Batchelor EK, Kapitsinou P, Pergola PE, Kovesdy CP, Jalal DI. Iron deficiency in chronic kidney disease: Updates on pathophysiology, diagnosis, and treatment. J Am Soc Nephrol. 2020;31(3):456-68.

Hanudel MR. Ferric citrate: cardio- and renoprotective in chronic kidney disease? Kidney Int. 2019;96(6):1277-9.

Block GA, Block MS, Smits G, Mehta R, Isakova T, Wolf M, et al. A pilot randomized trial of ferric citrate coordination complex for the treatment of advanced CKD. J Am Soc Nephrol. 2019;30(8):1495-504.

Choi YJ, Noh Y, Shin S. Ferric citrate in the management of hyperphosphataemia and iron deficiency anaemia: A meta-analysis in patients with chronic kidney disease. Br J Clin Pharmacol. 2021;87(2):414-26.

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failureDeveloped by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2021 sept. 21;42(36):3599-726.

Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJ, Doree C, et al. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021 nov. 1;4(11):e2133935.

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