Reticulocyte Hemoglobin Content Helps Avoid Iron Overload in Hemodialysis Patients: A Retrospective Observational Study

Discussion

The loss of blood due to hemodialysis procedures but also laboratory testing is responsible for the anemia that usually is normocytic, normochromic and slightly regenerative. This condition needs ESA therapy, which should be associated with the administration of iron, as its efficacy is strongly linked to the adequate supplementation of this important trace metal. Optimal iron dosage is mandatory in order to avoid inappropriate ectopic storage (particularly liver, spleen, hearth, endocrine system) with related specific organ injury (15). In fact, overdose leads to an epidemic overload of iron in the ESRD population; IV iron bypasses the biological safeguards for the transport and handling of iron and helps to intensify chronic kidney disease-associated oxidative stress and inflammation. As a consequence, indiscriminate use of IV iron can accelerate cardiovascular disease, promote microbial infections, aggravate eventual viral hepatitis, and worsen diabetes and diabetic complications in such patients. For these reasons IV iron should be judiciously used in this vulnerable population (6).

Thus, adequate supplementation of both ESA and iron is central to reaching the Hb target concentrations. With regard to iron supplementation, IV iron is required as iron absorption is reduced along the gastro-intestinal tract due to elevation of hepcidin causing iron deficiency in ESRD patients. Even slight excess iron as a result of prolonged exposure can lead to toxicity. This approach could seem to be exaggerated, but it is mandatory to prevent long-term complications of iron overload and maintain serum iron and total body iron levels within a normal range. In this regards, the CHr could represent a valid diagnostic alternative although conflicting results exist in the literature. In fact, a previous study reported that the analysis of CHr is not superior to MCH when screening for iron deficiency in elderly anemic hospitalized patients (16). Conversely, other investigations carried out in animals and humans demonstrated an important predictive role of CHr in the diagnosis of iron deficiency (17). In our population, patients of group A required minor iron supplementation based on this recent analytical approach, and this finding is in agreement with the latter reported study.

Administering the ideal iron dosage avoids important fluctuations in ESA dosage, identifies no-responders and improves health care costs. The cost reduction, due to tailored iron therapy, could be considered an apparently inconsistent issue but, taking into account the large number of patients on haemodialysis in Italy and the prolonged mean time of treatment (various years), this saving is noteworthy. Direct medical costs (laboratory tests including also false positive or true positive results, instrumental measurements and hospital services) should be further added to the cost of drug prescriptions. Finally, indirect costs such as those of morbidity and mortality should be not overlooked (18).

Medical errors is the third leading cause of death in the United States, after heart diseases and cancer, according to recently published findings (19), burdened by skyrocketing health care costs. Medication errors can occur in deciding which medicine and dosage regimen to use. Errors in prescribing include ineffective under-prescribing and inappropriate over-prescribing (20).

A limitation of this study could be the relatively small sample size, although a prolonged time of observation should be considered a strength.

In conclusion, the use of erythrocyte indexes and their related parameters allows avoidance of over-dosage of IV iron, which can potentially damage organs, and reduction in health care direct and indirect costs.