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Clinical Epidemiology
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Infection Risk with Bolus versus Maintenance Iron Supplementation in Hemodialysis Patients

M. Alan Brookhart, Janet K. Freburger, Alan R. Ellis, Lily Wang, Wolfgang C. Winkelmayer and Abhijit V. Kshirsagar
JASN July 2013, 24 (7) 1151-1158; DOI: https://doi.org/10.1681/ASN.2012121164
M. Alan Brookhart
*Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina;
†Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina;
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Janet K. Freburger
†Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina;
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Alan R. Ellis
†Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina;
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Lily Wang
†Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina;
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Wolfgang C. Winkelmayer
‡Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
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Abhijit V. Kshirsagar
§University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Abstract

Intravenous iron may promote bacterial growth and impair host defense, but the risk of infection associated with iron supplementation is not well defined. We conducted a retrospective cohort study of hemodialysis patients to compare the safety of bolus dosing, which provides a large amount of iron over a short period of time on an as-needed basis, with maintenance dosing, which provides smaller amounts of iron on a regular schedule to maintain iron repletion. Using clinical data from 117,050 patients of a large US dialysis provider merged with data from Medicare’s ESRD program, we estimated the effects of iron dosing patterns during repeated 1-month exposure periods on risks of mortality and infection-related hospitalizations during the subsequent 3 months. Of 776,203 exposure/follow-up pairs, 13% involved bolus dosing, 49% involved maintenance dosing, and 38% did not include exposure to iron. Multivariable additive risk models found that patients receiving bolus versus maintenance iron were at increased risk of infection-related hospitalization (risk difference [RD], 25 additional events/1000 patient-years; 95% confidence interval [CI], 16 to 33) during follow-up. Risks were largest among patients with a catheter (RD, 73 events/1000 patient-years; 95% CI, 48 to 99) and a recent infection (RD, 57 events/1000 patient-years; 95% CI, 19 to 99). We also observed an association between bolus dosing and infection-related mortality. Compared with no iron, maintenance dosing did not associate with increased risks for adverse outcomes. These results suggest that maintenance iron supplementation may result in fewer infections than bolus dosing, particularly among patients with a catheter.

  • Copyright © 2013 by the American Society of Nephrology
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Journal of the American Society of Nephrology: 24 (7)
Journal of the American Society of Nephrology
Vol. 24, Issue 7
July 2013
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Infection Risk with Bolus versus Maintenance Iron Supplementation in Hemodialysis Patients
M. Alan Brookhart, Janet K. Freburger, Alan R. Ellis, Lily Wang, Wolfgang C. Winkelmayer, Abhijit V. Kshirsagar
JASN Jul 2013, 24 (7) 1151-1158; DOI: 10.1681/ASN.2012121164

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Infection Risk with Bolus versus Maintenance Iron Supplementation in Hemodialysis Patients
M. Alan Brookhart, Janet K. Freburger, Alan R. Ellis, Lily Wang, Wolfgang C. Winkelmayer, Abhijit V. Kshirsagar
JASN Jul 2013, 24 (7) 1151-1158; DOI: 10.1681/ASN.2012121164
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Cited By...

  • Intravenous Iron Dosing and Infection Risk in Patients on Hemodialysis: A Prespecified Secondary Analysis of the PIVOTAL Trial
  • Post-PIVOTAL Iron Dosing with Maintenance Hemodialysis
  • Safety of Dynamic Intravenous Iron Administration Strategies in Hemodialysis Patients
  • Phosphate Binder, Ferric Citrate, Attenuates Anemia, Renal Dysfunction, Oxidative Stress, Inflammation, and Fibrosis in 5/6 Nephrectomized CKD Rats
  • Safety of Intravenous Iron in Dialysis: A Systematic Review and Meta-Analysis
  • Considerations and controversies in managing chronic kidney disease: An update
  • Anemia in Peritoneal Dialysis Patients; Iron Repletion, Current and Future Therapies
  • Epoetin Alfa and Outcomes in Dialysis amid Regulatory and Payment Reform
  • The Labile Side of Iron Supplementation in CKD
  • Receipt of Intravenous Iron and Clinical Outcomes among Hemodialysis Patients Hospitalized for Infection
  • Ferric Citrate Reduces Intravenous Iron and Erythropoiesis-Stimulating Agent Use in ESRD
  • Considerations and Challenges in Defining Optimal Iron Utilization in Hemodialysis
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