Ferric carboxymaltose is safe and more effective than oral iron for patients with decompensated cirrhosis and iron deficiency anemia, and demonstrates circulatory, renal and prognostic benefits

Ilias Tsiakas; Christina Koustousi; Grigorios Despotis; Dimitrios Biros; Spyridon Tsiouris; Lampros Lakkas; Reveka Konstantopoulou; Dimitrios Christodoulou; Haralampos Milionis; George N. Kalambokis

Authors Ilias Tsiakas, Christina Koustousi, Grigorios Despotis, Dimitrios Biros, Spyridon Tsiouris, Lampros Lakkas, Reveka Konstantopoulou, Dimitrios Christodoulou, Haralampos Milionis, George N. Kalambokis.

Abstract

Background Iron deficiency anemia (IDA) commonly complicates patients with decompensated cirrhosis (DC). We investigated the efficacy of intravenous ferric carboxymaltose (FCM) over oral iron in treating IDA in these patients, the circulatory and renal effects of each treatment, and the prognostic impact of FCM.

Methods We prospectively evaluated non-acutely anemic patients with DC and hemoglobin levels 8-10 g/dL: 58 with IDA (serum ferritin <30 ng/mL) and 90 without IDA. Patients with IDA received oral iron polymaltose (IP) for 3 months and those not achieving hemoglobin increases ≥2 g/dL switched to FCM. Systemic vascular resistance (SVR) as mean arterial pressure/cardiac output ratio, plasma renin activity (PRA), plasma aldosterone, glomerular filtration rate (GFR) and renal blood flow (RBF) were evaluated 3 months after each treatment. All patients with recurrent IDA during follow up received FCM. New/recurrent decompensation and survival rates were assessed
in patients with and without IDA.

Results Hemoglobin increased by ≥2 g/dL in 6/51 (11.7%) patients who tolerated IP, compared to 34/45 (75.5%; P<0.001) FCM-treated patients. FCM use was safe and, unlike IP, it significantly increased SVR, GFR and RBF, while significantly reducing PRA and plasma aldosterone (P<0.001). Percentage hemoglobin changes correlated with changes in SVR (r=0.533; P<0.001), GFR (r=0.775; P<0.001) and RBF (r=0.803; P<0.001). FCM-treated patients showed lower 5-year risk of decompensation (P=0.002) and mortality (P=0.006), and lower incidence of hepatorenal syndrome (n=0.03), than patients without IDA.

Conclusions FCM outperforms oral iron in ameliorating IDA in DC patients with DC. Addressing IDA yields positive circulatory, renal and prognostic outcomes.

Keywords Iron deficiency anemia, decompensated cirrhosis, ferric carboxymaltose, circulatory function, prognosis

Ann Gastroenterol 2025; 38 (6): 691-698