title: Intravenous iron and erythropoiesis-stimulating agents in haemodialysis: A systematic review and meta-analysis.
abstract: OBJECTIVE
  Higher dosages of erythropoiesis-stimulating agents (ESAs) have been associated with adverse effects. Intravenous iron is used to optimize ESA response and reduces ESA doses in haemodialysis patients; this meta-analysis evaluates the magnitude of this effect.
  
  
  METHODS
  A literature search was performed using MEDLINE, Embase and the Cochrane Collaboration Central Register of Clinical Trials from inception until December 2014, to identify randomized controlled trials of intravenous iron and ESA, in patients undergoing haemodialysis for end-stage kidney disease. Dosing of IV iron in concordance with the Kidney Disease Improving Global Outcomes guidelines was considered optimal iron therapy.
  
  
  RESULTS
  Of the 28 randomized controlled trials identified, seven met the criteria for inclusion in the meta-analysis. Results of random-effects meta-analysis show a statistically significant weighted mean (95% CI) difference of -1733 [-3073, -392] units/week in ESA dose for optimal iron versus suboptimal iron. The weighted average change in ESA dose was a reduction of 23% (range -7% to -55%) attributable to appropriate dosing of intravenous iron. A comparison of intravenous iron versus oral iron/no iron (five trials) showed a greater reduction in ESA dose, although this did not reach statistical significance (weighted mean difference, 95% CI: -2,433 [-5183, 318] units/week). The weighted average change in ESA dose across the five trials was a reduction of 31% (range -8% to -55%).
  
  
  CONCLUSIONS
  Significant reductions in ESA dosing may be achieved with optimal intravenous iron usage in the haemodialysis population, and suboptimal iron use may require higher ESA dosing to manage anaemia.
authors.affiliation: Renal Research, Gosford, Australia.
authors.forename: Simon D
authors.initials: SD
authors.lastname: Roger
authors.affiliation: Royal North Shore Hospital, St Leonards, Australia.
authors.forename: Martin
authors.initials: M
authors.lastname: Tio
authors.affiliation: Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Hyeong-Cheon
authors.initials: HC
authors.lastname: Park
authors.affiliation: Singapore General Hospital, Singapore.
authors.forename: Hui Lin
authors.initials: HL
authors.lastname: Choong
authors.affiliation: Clinical Research Centre, Hospital Serdang, Kajang, Malaysia.
authors.forename: Bakleong
authors.initials: B
authors.lastname: Goh
authors.affiliation: Vifor Pharma APAC, Singapore.
authors.forename: Timothy Robert
authors.initials: TR
authors.lastname: Cushway
authors.affiliation: Vifor Pharma, Melbourne, Australia.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Stevens
authors.affiliation: Department of Renal Medicine, King's College Hospital, London, UK.
authors.forename: Iain C
authors.initials: IC
authors.lastname: Macdougall
mesh_terms: D000328:Adult; D000740:Anemia / Q000188:drug therapy*; D006397:Hematinics / Q000008:administration & dosage*; D006801:Humans; D007275:Injections, Intravenous; D007501:Iron / Q000008:administration & dosage*; D006435:Renal Dialysis / Q000009:adverse effects*
chemical_list: D006397:Hematinics; D007501:Iron
keywords: ESA; chronic kidney disease; epoetin; haemodialysis; intravenous iron; meta-analysis