Bone marrow iron, iron indices, and the response to intravenous iron in patients with non-dialysis-dependent CKD

Abstract

Background: Information about iron stores and their relationship with transferrin saturation (TSAT), serum ferritin, and the erythropoietic response to iron therapy is scarce in anemic non-dialysis-dependent patients with chronic kidney disease (CKD). We examined the diagnostic utility of peripheral-iron indices and the erythropoietic response to intravenous iron as indices of iron store depletion using bone marrow iron as a reference test in anemic non-dialysis-dependent patients with CKD.

Study design: Diagnostic test study.

Setting & participants: 100 anemic (hemoglobin <11 g/dL) patients with CKD stages 3-5, not receiving epoetin and iron.

Index tests: TSAT index and serum ferritin level at baseline and increase in hemoglobin level 1 month after 200 mg of iron sucrose daily for 5 days.

Reference test: Bone marrow iron (assessed using aspiration and Perls' stain), depleted versus replete, at baseline.

Measurements: Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of peripheral-iron indices and erythropoietic response to describe bone marrow iron stores.

Results: Bone marrow iron stores were depleted in 48% of patients at baseline. In iron-depleted versus -replete subjects, mean hemoglobin level, median TSAT index, median serum ferritin level, and hemoglobin level increase after iron sucrose administration were 8.74 +/- 1.1 (SD) versus 9.22 +/- 0.9 g/dL (P = 0.02), 19% (interquartile range [IQR], 15%) versus 28% (IQR, 12%; P < 0.001), 100 (IQR, 131) versus 220 ng/mL (IQR, 213; P < 0.001), and 1.2 +/- 0.4 versus 0.8 +/- 0.3 g/dL (P < 0.001), respectively. TSAT, ferritin level, and increase in hemoglobin level AUROCs were similar: 0.75 (95% CI, 0.66-0.85), 0.76 (95% CI, 0.66-0.85), and 0.74 (95% CI, 0.65-0.84), respectively.

Limitations: Bone marrow iron as the index of iron stores.

Conclusions: Half the anemic patients with CKD stages 3-5 had depleted iron stores. Peripheral-iron indices and erythropoietic response had equivalent, but limited, utility in identifying depletion of bone marrow iron stores. Use of these indices to indicate depletion of iron stores should be reconsidered.