Letter to the Editor
Use of intravenous iron in anaemic critically ill patients with anemia
Uso de hierro intravenoso en pacientes anémicos ingresados en cuidados intensivos
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Leal-Noval, Manuel Muñoz Gómez, Manuel Casado Méndez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Santiago R." "apellidos" => "Leal-Noval" "email" => array:1 [ 0 => "srlealnoval@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Manuel" "apellidos" => "Muñoz Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Manuel" "apellidos" => "Casado Méndez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina Transfusional Perioperatoria, Universidad de Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de hierro intravenoso en pacientes anémicos ingresados en cuidados intensivos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the Beneitez Pastor editorial about the use of intravenous iron (IV Fe) in clinical practice, recently published in <span class="elsevierStyleItalic">Medicina Clínica</span>.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The author rightly points out the increasing use of different preparations of IV Fe in various clinical contexts, including patients with renal insufficiency, inflammatory bowel disease, heart failure or patients scheduled for major surgery, both for the treatment of iron deficiency anaemia and functional iron deficiency, with or without anaemia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The protocolized treatment of acute anaemia through the use of blood components, blood products and coagulation factors has led to an improvement in the clinical outcome in patients admitted to intensive care.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> However, up to 80% of patients without haemorrhage will develop anaemia during their stay in the ICU,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and this type of anaemia has received little consideration in the previously mentioned editorial.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These patients develop an anaemia whose origin is typically multifactorial, including chronic blood loss (dialysis, central lines and extractions for laboratory tests, among others) and inflammation-induced alterations in iron homeostasis and erythropoietic response.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> Absolute iron deficiency, as well as its sequestration in macrophages and hepatocytes (functional deficiency), limit its availability for the bone marrow, affecting erythropoiesis. All this would justify, at least theoretically, the administration of iron supplements in selected patients.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A recent meta-analysis included 5 randomized clinical trials with a total of 665 anaemic patients admitted to the ICU: 368 treated with iron and 297 with placebo or no treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Analysis of the data revealed that iron treatment did not decrease transfusion requirements, mortality or hospital stay, although patients treated with iron showed better ferritin values. However, the authors acknowledge that there is a high risk of bias in the studies included, that there were differences in the formulations, doses and duration of iron treatments, and that the confidence intervals of the values of the variables analyzed were broad, justifying the need for new studies.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A multicentre, randomized, controlled study has been recently published <span class="elsevierStyleItalic">(Ironman study)</span>.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> It was designed to test the hypothesis that, compared to a placebo, the administration of IV Fe (500<span class="elsevierStyleHsp" style=""></span>mg of iron carboxymaltose) to critically anaemic patients (haemoglobin <100<span class="elsevierStyleHsp" style=""></span>g/l) would reduce transfusion requirements during hospital stay and improve haemoglobin levels at discharge. IV Fe group patients received a total of 97 units of RBC concentrate versus 136 units administered to patients in the placebo group (RR: 0.71, 95% CI: 0.43–1.18<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.19). Haemoglobin values at discharge were significantly higher in those treated with IV Fe (107<span class="elsevierStyleHsp" style=""></span>g/l [95% CI: 97–115] versus 100<span class="elsevierStyleHsp" style=""></span>g/l [95% CI: 89–111], respectively; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02), even without discounting the effects of transfusions of packed red blood cells on it. These data suggest, although not documented, a possible beneficial effect of IV Fe administration in these patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Since iron is essential for bacterial growth, its administration could increase the already high risk of infection in the patient admitted to the ICU. However, the previously mentioned meta-analysis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and the <span class="elsevierStyleItalic">Ironman study</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> have not documented a higher rate of infection in patients treated with iron. Also, the recent discussion forum of 23 experts from 6 scientific societies that reviewed the safety of alternatives to allogeneic transfusion in surgical and/or critical patients, did not conclude that there was an increased risk of infection in patients who received IV Fe.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Therefore, the theoretical lack of safety associated with the administration of IV Fe in the context of critical illness does not seem justified.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite the controversy over its efficacy and safety, the use of IV Fe is increasingly common in the management of anaemia in patients admitted to the ICU. Studies are needed to investigate the population of patients who would benefit from the administration of IV Fe, the most appropriate preparations, doses and routes of administration and possible adverse reactions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Leal-Noval SR, Muñoz Gómez M, Casado Méndez M. Uso de hierro intravenoso en pacientes anémicos ingresados en cuidados intensivos. Med Clin (Barc). 2018;150:327–328.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Uso del hierro intravenoso en la clínica actual" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. 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