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Diagnosis of iron deficiency in chronic kidney disease

Jeffrey S Berns, MD
Section Editor
Thomas A Golper, MD
Deputy Editor
Alice M Sheridan, MD


Adequate iron stores are essential for achieving maximum benefit from erythropoietic-stimulating agents (ESAs), such as recombinant human erythropoietin (EPO) or darbepoetin alfa. Decreased iron stores or decreased availability of iron are the most common reasons for resistance to the effect of these agents.

The dialysis patient is in a state of continuous iron loss from gastrointestinal bleeding, blood drawing for lab tests, and/or, most importantly with hemodialysis, the dialysis treatment itself. Hemodialysis patients lose an average of 1 to 2 g of iron per year, though some patients may lose as much as 4 to 5 g per year [1,2]. Thus, iron deficiency will develop in virtually all dialysis patients receiving EPO or darbepoetin alfa, unless supplemental iron therapy is given orally or intravenously.

An overview of the diagnosis of iron deficiency in chronic kidney disease (CKD) is presented in this topic review. Discussions related to the use of iron, EPO, and darbepoetin in patients with CKD are presented separately. (See "Erythropoietin for the anemia of chronic kidney disease among predialysis and peritoneal dialysis patients" and "Erythropoietin for treatment of the anemia of chronic kidney disease in hemodialysis patients" and "Darbepoetin alfa for the management of anemia in chronic kidney disease".)


To assess iron stores and the availability of iron for erythropoiesis, the evaluation should include red blood cell indices, serum iron, total iron-binding capacity, percent transferrin saturation (TSAT), and serum ferritin. If iron deficiency is diagnosed, an appropriate evaluation for its cause should be undertaken. (See "Approach to the adult patient with anemia".)

Absolute iron deficiency — An important issue in the diagnosis of iron deficiency in the patient with CKD or end-stage renal disease (ESRD) is that the laboratory criteria are markedly different from those in patients with relatively normal renal function.


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Literature review current through: Sep 2016. | This topic last updated: Feb 24, 2016.
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