Diagnosis of iron deficiency in chronic kidney disease
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
Anemia is common among patients with chronic kidney disease (CKD), including those on dialysis. Anemia underlies many of the symptoms associated with reduced kidney function and is associated with increased mortality and hospitalizations [1-4]. Iron deficiency is the most common reversible cause of anemia among such patients.
This topic reviews methods to diagnose iron deficiency in individuals with CKD. The treatment of iron deficiency in nondialysis CKD, peritoneal dialysis, and hemodialysis patients is discussed elsewhere. (See "Treatment of iron deficiency in nondialysis chronic kidney disease (CKD) patients" and "Treatment of iron deficiency in peritoneal dialysis patients" and "Treatment of iron deficiency in hemodialysis patients".)
Overall approaches to anemia in nondialysis CKD, peritoneal dialysis, and hemodialysis patients are discussed elsewhere. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of anemia in hemodialysis patients" and "Treatment of anemia in peritoneal dialysis patients".)
Patients may have either absolute or functional iron deficiency.
●Absolute iron deficiency – Absolute iron deficiency is defined by severely reduced or absent storage iron in bone marrow, liver, and spleen.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ma JZ, Ebben J, Xia H, Collins AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999; 10:610.
- Xia H, Ebben J, Ma JZ, Collins AJ. Hematocrit levels and hospitalization risks in hemodialysis patients. J Am Soc Nephrol 1999; 10:1309.
- Collins AJ, Li S, St Peter W, et al. Death, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39%. J Am Soc Nephrol 2001; 12:2465.
- Collins AJ, Ma JZ, Ebben J. Impact of hematocrit on morbidity and mortality. Semin Nephrol 2000; 20:345.
- Thomas DW, Hinchliffe RF, Briggs C, et al. Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol 2013; 161:639.
- Babitt JL, Lin HY. Mechanisms of anemia in CKD. J Am Soc Nephrol 2012; 23:1631.
- Rambod M, Kovesdy CP, Kalantar-Zadeh K. Combined high serum ferritin and low iron saturation in hemodialysis patients: the role of inflammation. Clin J Am Soc Nephrol 2008; 3:1691.
- Nemeth E, Rivera S, Gabayan V, et al. IL-6 mediates hypoferremia of inflammation by inducing the synthesis of the iron regulatory hormone hepcidin. J Clin Invest 2004; 113:1271.
- Andriopoulos B Jr, Corradini E, Xia Y, et al. BMP6 is a key endogenous regulator of hepcidin expression and iron metabolism. Nat Genet 2009; 41:482.
- Babitt JL, Lin HY. Molecular mechanisms of hepcidin regulation: implications for the anemia of CKD. Am J Kidney Dis 2010; 55:726.
- Ganz T, Olbina G, Girelli D, et al. Immunoassay for human serum hepcidin. Blood 2008; 112:4292.
- Ashby DR, Gale DP, Busbridge M, et al. Plasma hepcidin levels are elevated but responsive to erythropoietin therapy in renal disease. Kidney Int 2009; 75:976.
- Zaritsky J, Young B, Wang HJ, et al. Hepcidin--a potential novel biomarker for iron status in chronic kidney disease. Clin J Am Soc Nephrol 2009; 4:1051.
- Coyne DW, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of the Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) Study. J Am Soc Nephrol 2007; 18:975.
- Singh AK, Coyne DW, Shapiro W, et al. Predictors of the response to treatment in anemic hemodialysis patients with high serum ferritin and low transferrin saturation. Kidney Int 2007; 71:1163.
- Fernández-Rodríguez AM, Guindeo-Casasús MC, Molero-Labarta T, et al. Diagnosis of iron deficiency in chronic renal failure. Am J Kidney Dis 1999; 34:508.
- Kalantar-Zadeh K, Höffken B, Wünsch H, et al. Diagnosis of iron deficiency anemia in renal failure patients during the post-erythropoietin era. Am J Kidney Dis 1995; 26:292.
- Stancu S, Stanciu A, Zugravu A, et al. Bone marrow iron, iron indices, and the response to intravenous iron in patients with non-dialysis-dependent CKD. Am J Kidney Dis 2010; 55:639.
- Stancu S, Bârsan L, Stanciu A, Mircescu G. Can the response to iron therapy be predicted in anemic nondialysis patients with chronic kidney disease? Clin J Am Soc Nephrol 2010; 5:409.
- Nissenson AR. Achieving target hematocrit in dialysis patients: new concepts in iron management. Am J Kidney Dis 1997; 30:907.
- Rocha LA, Barreto DV, Barreto FC, et al. Serum ferritin level remains a reliable marker of bone marrow iron stores evaluated by histomorphometry in hemodialysis patients. Clin J Am Soc Nephrol 2009; 4:105.
- Ratcliffe LE, Thomas W, Glen J, et al. Diagnosis and Management of Iron Deficiency in CKD: A Summary of the NICE Guideline Recommendations and Their Rationale. Am J Kidney Dis 2016; 67:548.
- Macdougall IC. What is the most appropriate strategy to monitor functional iron deficiency in the dialysed patient on rhEPO therapy? Merits of percentage hypochromic red cells as a marker of functional iron deficiency. Nephrol Dial Transplant 1998; 13:847.
- Sunder-Plassmann G, Hörl WH. Laboratory diagnosis of anaemia in dialysis patients: use of common laboratory tests. Curr Opin Nephrol Hypertens 1997; 6:566.
- Mittman N, Sreedhara R, Mushnick R, et al. Reticulocyte hemoglobin content predicts functional iron deficiency in hemodialysis patients receiving rHuEPO. Am J Kidney Dis 1997; 30:912.
- Bovy C, Tsobo C, Crapanzano L, et al. Factors determining the percentage of hypochromic red blood cells in hemodialysis patients. Kidney Int 1999; 56:1113.
- Fishbane S, Shapiro W, Dutka P, et al. A randomized trial of iron deficiency testing strategies in hemodialysis patients. Kidney Int 2001; 60:2406.
- Tessitore N, Girelli D, Campostrini N, et al. Hepcidin is not useful as a biomarker for iron needs in haemodialysis patients on maintenance erythropoiesis-stimulating agents. Nephrol Dial Transplant 2010; 25:3996.
- Macdougall IC, Malyszko J, Hider RC, Bansal SS. Current status of the measurement of blood hepcidin levels in chronic kidney disease. Clin J Am Soc Nephrol 2010; 5:1681.