American Journal of Kidney Diseases
Volume 43, Issue 4 , Pages 671-684, April 2004

A low serum iron level is a predictor of poor outcome in hemodialysis patients☆

Presented in part in the annual meeting of the American Society of Nephrology, November 4–6, 2003, San Diego, CA.

  • Kamyar Kalantar-Zadeh, MD, MPH

      Affiliations

    • Division of Nephrology and Hypertension, Harbor-University of California at Los Angeles Medical Center, Torrance, USA
    • David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, USA
    • University of California, Los Angeles School of Public Health, Los Angeles, CA, USA
    • Corresponding Author InformationAddress reprint requests to Kamyar Kalantar-Zadeh, MD, UCLA Assistant Professor of Medicine and Pediatrics, Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Harbor Mailbox 406, 1000 West Carson St, Torrance 90509-2910 USA
    • ,
  • Charles J. McAllister, MD

      Affiliations

    • DaVita Inc, Torrance, USA
    • ,
  • Robert S. Lehn, MT

      Affiliations

    • DaVita Laboratories, Deland, FL, USA
    • ,
  • Enwu Liu, MS

      Affiliations

    • University of California, Los Angeles School of Public Health, Los Angeles, CA, USA
    • ,
  • Joel D. Kopple, MD

      Affiliations

    • Division of Nephrology and Hypertension, Harbor-University of California at Los Angeles Medical Center, Torrance, USA
    • David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, USA
    • University of California, Los Angeles School of Public Health, Los Angeles, CA, USA

Received 29 September 2003; received in revised form 5 December 2003; accepted 5 December 2003.

Abstract 

Iron administration has been implicated as a cause of poor clinical outcome in maintenance hemodialysis (MHD) patients. However, the role of low iron levels in the clinical outcome of MHD patients is not clear. We examined the predicting value of baseline serum iron level on prospective mortality and hospitalization in a cohort of all 1,283 MHD patients from 10 DaVita dialysis facilities in Los Angeles County, CA. Patients aged 57.8 ± 15.2 years included 49% men, 45% Hispanics, 25% African Americans, and 53% patients with diabetes. During the first 3 months of the cohort, 97% of patients were administered erythropoietin (EPO) and 60% were administered intravenous iron (gluconate and/or dextran) at least once. During a 12-month follow-up, mortality was significantly greater (23%) in the lowest serum iron quartile (<45.3 μg/dL [<8.1 μmol/L]) compared with other quartiles (10% to 12%). Multivariate Poisson and Cox models adjusted for demographic features, dialysis dose and vintage, serum albumin and ferritin and blood hemoglobin concentrations, and administered EPO and iron doses showed that both serum iron level and iron saturation ratio had significant, but inverse, associations with prospective mortality and hospitalization. There was a statistically significant trend toward greater rates of mortality and hospitalization with lower serum iron levels. This reverse association remained significant in a subcohort of 322 MHD patients after additional adjustments for comorbid conditions and serum C-reactive protein level to reflect inflammation. Low baseline serum iron indicators are associated with increased mortality and hospitalization in MHD patients independent of hemoglobin level, EPO and iron doses, indicators of nutrition and inflammation, and comorbid conditions. Clinical trials to examine the role of iron administration in improving morbidity and mortality by increasing serum iron levels in MHD patients are required.

Keywords:  Serum iron, transferrin saturation ratio, mortality, hospitalization, hemodialysis (HD), reverse epidemiology, erythropoietin (EPO)

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☆ Supported in part by a National Kidney Foundation Young Investigator Award (K.K.-Z.); the Nutritional/Inflammatory Evaluation in Dialysis Study is supported by grant no. DK61162 from the National Institute of Diabetes, Digestive and Kidney Diseases (K.K.-Z.); and General Clinical Research Center grant no. M01-RR00425 from the National Centers for Research Resources, The National Institutes of Health. K.K.-Z. is a member of a speaker bureau of Watson Inc and Ortho Biotech Inc and has a research grant from Amgen Inc.

PII: S0272-6386(04)00010-1

doi:10.1053/j.ajkd.2003.12.029

American Journal of Kidney Diseases
Volume 43, Issue 4 , Pages 671-684, April 2004

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