Kidney Week Educational Symposia-“Pumping” Iron for CKD

Video Transcription

Video Summary

The symposium “Pumping Iron for CKD” reviews why anemia is common in chronic kidney disease (CKD) and how iron deficiency and iron handling abnormalities complicate treatment. Meredith Atkinson outlines that anemia prevalence rises with CKD stage due mainly to reduced erythropoietin (EPO) production and iron deficiency/restriction. Iron availability is rate-limiting for erythropoiesis, and inadequate iron is a frequent cause of ESA (erythropoiesis-stimulating agent) hyporesponsiveness. Clinicians typically assess iron with ferritin and transferrin saturation (TSAT), though ferritin is confounded by inflammation. CKD patients lose iron from blood loss (dialysis circuits, labs, procedures) and often absorb oral iron poorly. IV iron bypasses impaired absorption and hepcidin-mediated “iron trapping,” but has driven higher ferritin levels and concerns about iron loading (oxidative stress, inflammation, infection risk, tissue injury), motivating alternative approaches.<br /><br />Dr. Selewski explains dysregulated iron metabolism: inflammation increases hepcidin (also reduced renal clearance in CKD), which internalizes ferroportin and blocks iron export from enterocytes, hepatocytes, and macrophages, causing functional iron deficiency (low TSAT with high ferritin). He distinguishes true iron deficiency (low TSAT and low ferritin) from functional deficiency and highlights links among iron deficiency, EPO, and elevated FGF23, which may relate to anemia and CKD outcomes.<br /><br />Dr. McDougall reviews emerging therapies: newer oral agents show mixed results (heme iron polypeptide disappointing; liposomal iron limited; ferric citrate promising as both phosphate binder and iron source, possibly lowering FGF23). Other strategies include intradialytic ferric pyrophosphate citrate, hepcidin antagonists (early phase), and HIF–prolyl hydroxylase inhibitors that raise EPO and lower hepcidin, potentially improving iron utilization.

Asset Subtitle

Meredith Atkinson, Isidro Salusky, Iain Macdougall
Support is provided by an educational grant from Akebia Therapeutics, Inc.

Keywords

chronic kidney disease anemia

erythropoietin deficiency

iron deficiency and restriction

ESA hyporesponsiveness

ferritin and transferrin saturation

hepcidin ferroportin pathway

functional iron deficiency

intravenous iron therapy risks

HIF prolyl hydroxylase inhibitors