Oral versus intravenous iron supplementation and six-month hemoglobin and iron-status outcomes in pediatric hemodialysis: a two-center retrospective cohort study

Background Anemia is a common complication in children with chronic kidney disease (CKD), particularly those undergoing hemodialysis. Iron supplementation is essential for optimizing erythropoiesis, but the optimal route of administration, oral versus intravenous, remains debated in pediatric practice. This study aimed to compare six-month hematologic and iron-status outcomes associated with oral and intravenous iron therapy among pediatric hemodialysis patients at two tertiary centers. Methods This retrospective study included 30 pediatric maintenance-hemodialysis patients receiving individualized intravenous (IV) or oral (PO) iron treatment. Treatment route was selected by the treating physician. The primary outcome was hemoglobin at six months. The primary analysis compared PO with IV iron using analysis of covariance adjusted for baseline hemoglobin, log-transformed baseline C-reactive protein (CRP), and dialysis vintage, with HC3 robust standard errors. Ferritin, transferrin saturation (TSAT), other iron-status indices, epoetin alfa use, complications, and packed-cell transfusions were evaluated as secondary outcomes. Results Fifteen patients received IV iron and 15 received PO iron. Mean hemoglobin increased by 0.67 ± 1.76 g/dL in the IV group and 1.76 ± 2.45 g/dL in the PO group. The direct between-group difference in change was 1.09 g/dL (95% CI, − 0.52 to 2.69; P = 0.175). In the primary adjusted analysis ( n = 28), the PO-minus-IV difference in six-month hemoglobin was 1.31 g/dL (95% CI, − 0.56 to 3.18; P = 0.161). All sensitivity analyses were likewise non-significant. Ferritin increased within both groups, but its between-group change did not differ significantly. An exploratory unadjusted change-score analysis suggested a greater increase in TSAT in the PO group; however, the baseline-adjusted comparison did not remain significant after false-discovery-rate correction. Complications occurred in 8/15 PO and 7/15 IV recipients ( P = 1.000), while packed-cell transfusion occurred in 2/15 and 6/15, respectively ( P = 0.215). No serious adverse event was documented. Conclusion In this small, non-randomized cohort, PO and IV iron were not associated with a statistically detectable difference in adjusted six-month hemoglobin. Wide confidence intervals, baseline imbalances, individualized treatment selection, and potential residual confounding preclude conclusions regarding superiority, equivalence, or a preferred route of administration.