Evidence for tissue iron overload in long-term hemodialysis patients and the impact of withdrawing parenteral iron

Background/aims Erythropoiesis in long-term hemodialyzed (LTH) patients is supported by erythropoietin (rHuEpo) and intravenous (IV) iron. This treatment may end up in iron overload (IO) in major organs. We studied such patients for the parameters of IO in the serum and in major organs. Methods Patients were treated with rHuEpo (68 x 103 units x 13/wk) and IV 100 mg ferric saccharate. Results Of 115 patients, 21 had serum ferritin (SF) > 1000 ng/mL. This group was further analyzed. Their SF and transferrin saturation (TSAT) were 2688 +/- 1489 ng/mL and 54.2 +/- 32.7%, respectively (vs. 125360 ng/mL and 2050% in normal controls). Serum hepcidin was 60.1 +/- 29.5 nm (vs. 10.61 +/- 6.44 nm in controls) (P < 0.001). Nineteen patients had increased malonyldialdehyde, a product of lipid peroxidation, indicating oxidative stress. T2* MRI disclosed in 19 of 21 patients moderate to severe IO in the liver and spleen, in three of eight patients in the pancreas, but in no patient in the heart. After stopping IV iron for a mean of 12 months, while continuing rHuEpo, the mean SF decreased in 11 patients to 1682 ng/mL and the mean TSAT decreased to 28%, whereas hemoglobin did not change indicating that tissue iron was utilized. Conclusion High SF correlates with IO in the liver and spleen, but not in the heart.