Pediatr Nephrol (2016) 31:819–826
DOI 10.1007/s00467-015-3284-2
ORIGINAL ARTICLE
Comparison of reticulocyte hemoglobin equivalent
with traditional markers of iron and erythropoiesis
in pediatric dialysis
Sarka Davidkova 1 & Timothy D. Prestidge 2 & Peter W. Reed 3 &
Tonya Kara 4 & William Wong 4 & Chanel Prestidge 4
Received: 17 May 2015 / Revised: 19 November 2015 / Accepted: 19 November 2015 / Published online: 14 December 2015
# IPNA 2015
Abstract
Background Anemia is a major complication for patients on
chronic dialysis. Erythropoietin is effective if iron is available,
however unnecessary iron supplementation results in iron
overload. Reticulocyte hemoglobin equivalent (Ret-He) may
be useful for assessing iron status.
Methods A national retrospective cohort study including all
children on chronic dialysis in New Zealand between 2007
and 2013, pairing Ret-He with demographic information, ane-
mia indices, and markers of iron status.
Results In 606 observations, we found a modest relationship
between Ret-He and transferrin saturation (TSAT) (r=0.34,
p<0.001) and a poor correlation between Ret-He and ferritin
(r=0.09, p=0.04). There was a negative correlation between
ferritin and hemoglobin (r=−0.14, p=0.002), a weak positive
correlation between TSAT and hemoglobin (r= 0.12, p=
0.007), and a modest positive correlation between Ret-He
and hemoglobin (r=0.22, p<0.001). The diagnostic perfor-
mance of Ret-He to detect absolute iron deficiency (cut-off
value 28.9 pg, sensitivity 90 %, specificity 75 %, AUC 0.87)
was good.
* Chanel Prestidge
chanelp@adhb.govt.nz
1
Department of Pediatrics, Starship Children’s Hospital,
Auckland, New Zealand
2
Blood and Cancer Centre, Starship Children’s Hospital,
Auckland, New Zealand
3
Children’s Research Centre, Starship Children’s Hospital,
Auckland, New Zealand
4
Department of Nephrology, Starship Children’s Hospital, Park Road,
Private Bag 92024, Auckland 1142, New Zealand
Conclusions Ret-He is a more relevant marker of iron status
than ferritin and TSAT. This supports prospectively testing
Ret-He to distinguish between iron deficiency and suboptimal
erythropoietin dosing as competing causes for anemia. Ferritin
is an unhelpful biomarker of iron deficiency in this setting.
Keywords Anemia . End-stage kidney disease .
Iron deficiency . Reticulocyte hemoglobin equivalent .
Ferritin . TSAT . children
Introduction
Despite the use of recombinant human erythropoietin
(rHuEPO) and iron supplementation, anemia remains a major
complication in children with chronic kidney disease (CKD),
especially for those on chronic dialysis [1–3]. Anemia in turn
is associated with increased morbidity and mortality and re-
duced quality of life in children and young people with CKD
[1, 4–6].
Other than erythropoietin insufficiency and a shortened red
blood cell life span, iron deficiency is the most common cause
of anemia in this population [3, 7–9]. Dialysis patients are
particularly at risk of absolute iron deficiency due to blood
loss from blood testing, the extra-corporeal circuit and for
some, vascular access surgeries. Dietary restrictions and re-
duced appetite can lead to poor iron intake, and medications
such as gastric acid inhibitors and phosphate binders further
reduce iron absorption and thus available iron. In addition,
inflammation, which commonly coexists with or complicates
dialysis, results in elevated hepcidin. Hepcidin reduces iron
absorption further and inhibits the release of existing iron from
reticuloendothelial stores, limiting iron available for erythro-
poiesis [10, 11]. Furthermore, patients with CKD who receive
rHuEPO treatment have increased iron requirements due to
820
supra physiological erythropoiesis. Therefore, the risk of func-
tional iron deficiency, defined as insufficient iron availability
to meet the demands of stimulated erythropoiesis, even though
the total body iron stores may not be depleted, is high [12].
Both absolute and functional iron deficiency ultimately
limit the effectiveness of rHuEPO therapy, resulting in high
dosing and costs [13, 14]. As in adults, the appropriate iron
supplementation in the pediatric population on dialysis can
improve the erythropoietic response to rHuEPO [15–17]. On
the other hand, unnecessary iron treatment, especially in the
parenteral form, can be associated with serious immediate and
long-term side effects. Therefore, evaluation of iron status is
an essential part of assessment and management of anemia in
CKD [7, 18, 19].
The traditional biomarkers for iron availability, serum fer-
ritin and transferrin saturation (TSAT), are recognized as sub-
optimal measures of iron status in patients with CKD. Serum
ferritin reflects total body iron stores but is also an acute phase
reactant, making its level difficult to interpret in patients with
CKD [20, 21]. In fact, rather than diagnosing an iron-limited
anemic state, serum ferritin has been found to have an inverse
relationship with hemoglobin (Hb) in both children on dialysis
and with non-dialysis CKD [1, 22]. The TSAT (serum iron
divided by total iron binding capacity) is also used as a marker
of iron availability for erythropoiesis [7]. However, TSAT
levels display diurnal fluctuation [23] and can be falsely ele-
vated when transferrin synthesis is reduced in the setting of
malnutrition or chronic disease [20]. Despite the evidence,
serum ferritin and TSAT continue to be commonly used as
the primary tools in assessment of iron status in renal anemia,
partly due to a lack of accepted and available alternative
measures.
A number of other biomarkers have been evaluated to as-
sess iron availability for erythropoiesis and predict response to
iron therapy in the CKD population. These markers may not
all be widely available and their diagnostic performance is
variable [7, 18, 19, 24]. One marker, reticulocyte hemoglobin
content, reflects iron availability for incorporation into reticu-
locytes in real time, over the preceding 2–4 days [25]. It is
measured by flow cytometry on ADVIA120 and 2120 ana-
lyzers (called CHr) and on the widely used XE-2100 Sysmex
analyzer (called Ret-He) [26–28]. Ret-He has been found to
be a marker of iron availability for erythropoiesis in adults on
hemodialysis, although the cut-off values, specificity, and sen-
sitivity vary [27, 29, 30]. While reticulocyte hemoglobin con-
tent can be a reliable screening tool for iron deficiency in
otherwise healthy infants and children [31, 32], evidence re-
garding the utility of Ret-He to assess iron availability in chil-
dren on chronic dialysis is not available.
The Ret-He parameter has been available in our laboratory
since 2005. The national pediatric renal service at Starship
Children’s Hospital has been monitoring this parameter in all
children on chronic dialysis since July 2007. In this study, we
Pediatr Nephrol (2016) 31:819–826
aimed to investigate the relationship between Ret-He and the
currently used traditional markers of iron and erythropoiesis in
pediatric patients on chronic dialysis. We hypothesized that
Ret-He is a clinically useful tool for the evaluation of iron
status in this population.
Materials and methods
Study design and settings
This was a national retrospective cohort study of children with
end-stage kidney disease (ESKD) on chronic dialysis under
the care of the pediatric national renal service at Starship Chil-
dren’s Hospital in New Zealand.
Participants
All patients under 18 years of age on dialysis for a min-
imum of 3 months between July 1, 2007 and June 30,
2013 were eligible. The study period commenced from
the time Ret-He was routinely included in our dialysis
database. Each patient’s diagnosis history was screened
for alternative causes of anemia, and any patient with
such diagnoses was excluded. Participant data was cen-
sored if they received a renal transplant, died, or were
transferred to adult services. Participants were managed
with rHuEPO and iron therapy according to local proto-
col, aiming to maintain Hb between 100 and 120 g/l for
children under 6 months and between 110 and 130 g/l for
those over 6 months of age. Parenteral and/or oral iron
replacement was provided to target a TSAT above 0.2 and
serum ferritin between 200 and 500 mg/l.
Data collection
Data were collected from the department database and the
hospital and laboratory electronic record systems. The da-
tabase contains clinical and laboratory data of all pediatric
dialysis patients from inpatient and outpatient encounters.
Data obtained from the database were verified for accura-
cy with the hospital and laboratory electronic systems and
were entered into an Excel data spreadsheet in de-
identified form. The data included demographic variables,
type of renal disease (as defined by the European Renal
Association-European Dialysis Transplant Association
(ERA-EDTA) [33]), anthropometric data, the mode, dura-
tion, and outcome of dialysis and episodes of peritonitis.
Anemia and iron status indices included paired data of
Ret-He with Hb, reticulocyte count, serum iron, ferritin,
total iron binding capacity, TSAT, and dose of rHuEPO at
multiple observations from each patient. The observations
were determined by Ret-He data. Missing height data at
Pediatr Nephrol (2016) 31:819–826 821

observations were determined by extrapolation using the Table 1 Demographic and clinical characteristics of study population
most recent preceding and succeeding height percentile Characteristic n (%)
from WHO growth charts.
Female patients 24 (53 %)
Statistical analysis Previous renal transplant 4 (9 %)
Primary renal diagnosis
Statistical analysis was conducted with the use of statistical Congenital 16 (36 %)
software JMP 10.0 (SAS Inc). Descriptive statistical analysis Glomerulopathy 15 (33 %)
was performed and normally distributed data were reported as Vasculitis 4 (9 %)
mean and standard deviation. Skewed data were reported as Metabolic 1 (2 %)
median and interquartile range (IQR). To allow for the non- Ischemia 5 (11 %)
independence of the repeated observations from each patient, Other 4 (9 %)
Bland–Altman multiple linear regression was used to deter- Native kidneys in situ at study enrolment 41 (91 %)
mine the within-patient correlation between Ret-He and tradi- Dialysis modality during study
tional markers of iron deficiency (ferritin and TSAT), Hb, and PD only 26 (58 %)
reticulocyte count within each patient [34]. Receiver operating HD only 4 (9 %)
characteristic (ROC) analysis was utilized to determine the PD and HD 15 (33 %)
performance of Ret-He in diagnosing absolute iron deficiency Age (years) at start of dialysis in years 6.7 [1.6–12.6]
anemia. The presence of absolute iron deficiency anemia was (median [IQR])
defined as Hb less than 100 g/l in children younger than <1 year 6 (13 %)
6 months or less than 110 g/l in children over 6 months, with 1–<5 years 12 (27 %)
ferritin less than 100 mcg/l, and TSAT less than 0.2. Addition- 5–<12 years 15 (33 %)
ally, we analyzed those with apparent “functional iron defi- 12–18 years 12 (27 %)
ciency” anemia, defined by Hb less than 100 g/l under Age (years) at study enrolment (median [IQR]) 7.6 [1.8–12.7]
6 months of age or 110 g/l older than 6 months of age with <1 year 5 (11 %)
TSAT of less than 0.2 and ferritin >200 mcg/l. The Ret-He cut- 1–<5 years 11 (24 %)
off was established based on the optimal combination of sen- 5–<12 years 18 (40 %)
sitivity and specificity. 12–18 years 11 (24 %)
Outcome of dialysis
Renal transplant 26 (58 %)
Results Death 4 (9 %)
Transfer to adult service on ongoing dialysis 8 (18 %)
Patient characteristics Ongoing dialysis under pediatric care 7 (16 %)
Duration of dialysis in months 15.5 [10.9–38.6]
Forty-five patients satisfied inclusion criteria. Patient charac- (median [IQR])
teristics are summarized in Table 1. Patients were followed up <6 months 5 (11 %)
for a median of 14.8 months (IQR 10.9–29.6 months). 6–<12 months 9 (20 %)
Follow-up was discontinued during the study period in 38 12 mo–<24 months 14 (31 %)
patients (84 %) due to renal transplant, death, or transfer to 24 mo–<48 months 10 (22 %)
the adult services. Fifty-eight percent of patients were on peri- >48 months 7 (16 %)
toneal dialysis, however only a third of patients required at Duration of follow-up in months (median [IQR]) 14.8 [10.9–29.6]
least one change of dialysis modality. rHuEPO was used con- Peritonitis during study 27 (60 %)
tinuously throughout the observation period in 25 patients Episodes of peritonitis per patient (median [IQR]) 1 [0–3]
(56 %), intermittently in 18 patients (40 %), and not at all in ACE inhibitor treatment 22 (49 %)
two patients (4 %). rHuEPO treatment 43 (96 %)

IQR interquartile range, HD hemodialysis, PD peritoneal dialysis,

Anemia and iron status characteristics
The final data set contained 606 observations of paired Ret-He
data with anemia and iron status indices. The median number
of observations per patient was seven (IQR 4–20). The serum
ferritin was missing in 60 observations, TSAT in 62 observa-
tions, Hb in seven observations, and reticulocytes in three
rHuEPO human recombinant erythropoietin, ACE angiotensin-
converting enzyme
observations. The weekly rHuEPO dose could not be accu-
rately calculated in 210 observations due to missing weight
data.
822 Pediatr Nephrol (2016) 31:819–826

Table 2 Anemia and iron status

characteristics Characteristics Number of observations

Ret-He (pg) (median [IQR]) 606 31.2 [28.6–32.9]

Hemoglobin (g/l) 599
<6 months of age (mean (SD)) 6 108 (10.6)
<100 g/l 1 17 %
100–130 g/l 5 83 %
≥6 months of age (mean (SD)) 593 111 (19.7)
<110 g/l 269 45 %
110–130 g/l 231 39 %
>130 g/l 93 16 %
Reticulocyte count (median [IQR]) 603 52 [36–71]
Ferritin (mcg/l) (median [IQR]) 546 282.5 [168–507.5]
<100 mcg/l 68 12 %
100–500 mcg/l 341 63 %
>500 mcg/l 137 25 %
TSAT (median [IQR]) 544 26 [19–36]
<0.2 154 28 %
≥0.2 390 72 %
rHuEpo treatment 606 569 (94 %)
rHuEpo dose (weekly IU/m2 BSA) (median [IQR]) 372 6365.2 [4643.1–9084.50]
Dialysis modality at observation 606
PD 381 63 %
HD 225 37 %

IQR interquartile range, Ret-He reticulocyte hemoglobin content, HD hemodialysis, PD peritoneal dialysis,
rHuEPO recombinant human erythropoietin, TSAT transferrin saturation, BSA body surface area

Anemia and iron status characteristics are given in Table 2.
The median Ret-He was 31.2 pg (IQR 28.6–32.9). The mean
Hb in patients under 6 months of age was 108 g/l, and 17 % of
patients in this age group were classified as anemic. In chil-
dren over 6 months of age, the mean Hb was 111 g/l; the
proportion of anemia in this group was 45 %. The majority
of observations were measured while receiving rHuEPO. The
median weekly dose of rHuEPO, where the body surface area
(BSA) could be calculated, was 6365 IU/m2. The majority of
observations (94 %) were obtained at least 1 month after an
episode of peritonitis, minimizing the confounding effect of
acute inflammation on ferritin and transferrin.
Association of Ret-He with anemia and traditional
markers of iron status
In the multiple linear regression analysis, there was a modest
relationship between Ret-He and TSAT in 544 observations
on 45 patients (r=0.34, p<0.001). The correlation between
Ret-He and TSAT was stronger in patients on hemodialysis

Fig. 1 a Correlation between serum ferritin and hemoglobin (r=−0.14, The average regression lines for each individual are shown (observations
p value=0.002). The average regression lines for each individual are = 538, individuals = 45). c Correlation between Ret-He and hemoglobin
shown (observations = 539, individuals = 45). b Correlation between (r = 0.22, p value <0.001). The average regression lines for each
transferrin saturation (TSAT) and hemoglobin (r=0.12, p value=0.007). individual are shown (observations = 599, individuals = 45)
Pediatr Nephrol (2016) 31:819–826
Fig. 2 ROC curve of reticulocyte hemoglobin equivalent (Ret-He) to
detect absolute iron deficiency anemia (observations = 536)
(r=0.47, p value <0.001) than on peritoneal dialysis (r=0.22,
p<0.001). Poor correlation between Ret-He and serum ferritin
was noted (r=0.09, p=0.04). When segregating patients by
dialysis modality, the correlation was present in those on he-
modialysis (r=0.27, p=0.001), but lost in patients on perito-
neal dialysis (r=−0.03, p=0.63). There was a weak negative
correlation between hemoglobin and serum ferritin (r=−0.14,
p=0.002) (Fig. 1a). There was no correlation in patients on
hemodialysis (r=−0.06, p=0.42) in comparison to those on
peritoneal dialysis (r=−0.21, p=0.0004). A weak positive cor-
relation was found between TSAT and hemoglobin (r=0.12,
p=0.007) (Fig. 1b). As was seen with Ret-He, this relationship
was lost in patients on peritoneal dialysis (r=0.05, p=0.37) in
comparison to those on hemodialysis (r=0.15, p=0.03). As
shown in Fig. 1c, modest correlation was noted between Ret-
He and hemoglobin (r=0.22, p<0.001). There was no associ-
ation between Ret-He and reticulocyte count (r=−0.03, p=
0.48). Ret-He and rHuEPO weekly dose were modestly neg-
atively correlated (r=−0.26, p<0.001).
Fig. 3 ROC curve of reticulocyte hemoglobin equivalent (Ret-He) to
detect functional iron deficiency anemia (observations = 536)
823
Table 3 Combined iron parameter results categorized by hemoglobin
Iron parameter Low Hb Target Hb
Ferritin <100 TSAT <0.2 Ret-He <28.9 7 (59 %) 5 (41 %)
Ret-He ≥28.9 1 (5 %) 20 (95 %)
TSAT ≥0.2 Ret-He <28.9 3 (30 %) 7 (70 %)
Ret-He ≥28.9 3 (15 %) 17 (85 %)
Ferritin 100–500 TSAT <0.2 Ret-He <28.9 24 (67 %) 12 (33 %)
Ret-He ≥28.9 21 (31 %) 47 (69 %)
TSAT ≥0.2 Ret-He <28.9 19 (51 %) 18 (49 %)
Ret-He ≥28.9 67 (39 %) 104 (61 %)
Ferritin >500 TSAT <0.2 Ret-He <28.9 13 (100 %) 0 (0 %)
Ret-He ≥28.9 3 (43 %) 4 (57 %)
TSAT ≥0.2 Ret-He <28.9 18 (75 %) 6 (25 %)
Ret-He ≥28.9 41 (44 %) 52 (56 %)
TSAT transferrin saturation, Ret-He reticulocyte hemoglobin equivalent,
Low Hb Hemoglobin <100 g/l if<6 months old and<110 g/l if>6 months
old, Target Hb >100 g/l if <6 months old and>110 g/l if>6 months old
The goal was to determine the diagnostic performance
of Ret-He against traditional diagnostic markers of iron
deficiency anemia. The ROC analysis demonstrated that a
cut-off Ret-He value of 28.9 pg is able to detect absolute
iron deficiency anemia with the best combination of 90 %
sensitivity and 75 % specificity. The area under the curve
(AUC) was 0.87 (Fig. 2). When using ROC analysis to
evaluate the diagnostic performance of Ret-He to detect
“functional iron deficiency anemia” as defined by a low
TSAT but normal to high ferritin, a Ret-He value of
27.7 pg detected this with 55 % sensitivity and 83 % spec-
ificity. The AUC was 0.721 (Fig. 3). Finally, given the
limitations of ferritin, we additionally performed ROC
analysis defining iron deficiency anemia with the same
Hb values and a TSAT <0.2 but with no inclusion of ferri-
tin. In this setting, the best cut-off value for Ret-He was
28.8 pg with 63 % sensitivity and 79.5 % specificity, AUC
0.73 (figures not shown).
Using the Ret-He cut-off of 28.9, the data based on all
three iron parameters for patients with low hemoglobin
versus target hemoglobin are presented in Table 3. Using
Ret-He, 38 % of patients with low hemoglobin would be
predicted to have iron-limited erythropoiesis contributing
to their anemia. Similarly, using low ferritin and/or low
TSAT, 34 % are identified as iron limited. However,
44 % of those with low Ret-He are not identified by the
ferritin/TSAT criteria, and 37 % of those with low ferritin
and/or TSAT are not identified as iron limited by the Ret-
He method. For patients with hemoglobin in the target
range, 16 % are identified as potentially iron-limited de-
spite normal hemoglobin levels when using Ret-He,
whereas 38 % of patients with normal hemoglobin have a
low ferritin or TSAT.
824
Discussion
Anemia remains a major clinical challenge when managing
patients with CKD. While anemia is associated with increased
morbidity and mortality, both iron overload and high doses of
rHuEPO are also associated with poor outcomes [13, 14].
Therefore, when correcting anemia, accurate measurement
of iron status is required to avoid unnecessary iron supplemen-
tation yet recognize when use of rHuEPO alone will be insuf-
ficient. The currently accepted markers of iron status in CKD,
TSAT and serum ferritin, are already known to have limited
reliability in assessing iron availability in patients on dialysis
[7, 10]. While newer and more sensitive and specific methods,
including the Ret-He parameter, have become available, the
specificity, sensitivity, and cut-off Ret-He values vary in pub-
lished studies and have not been reported in the pediatric pop-
ulation to date [26, 29, 30, 35].
Our results, in agreement with other reports [1, 22, 27],
confirm the poor correlation between Hb and ferritin (r=
−0.14) and highlight the limitations of ferritin as a reliable
marker of iron availability in patients on dialysis. Even
allowing for difficulties that exist in determining iron status
in this population, employing a poorly or negatively correlated
variable to guide therapy is questionable and the widespread
incorporation of ferritin into decision-making algorithms for
iron management in dialysis lacks evidence. Ferritin levels,
rather than revealing useful information on iron metabolism,
more likely reflect the degree of chronic inflammation over
time, which explains the negative correlation with Hb. In con-
trast, Ret-He was positively correlated with Hb in our study
(r=0.22), and demonstrated stronger correlation than TSAT
with Hb (r=0.12) and therefore may be a more helpful bio-
marker. Though an individual Ret-He value only reflects iron
availability in the preceding few days, it is not an acute phase
reactant and is more specific to erythropoietic activity than
ferritin. While Hb takes several months to generate, patients
with satisfactory Ret-He at one time point likely had iron
available during the recent past, explaining the positive corre-
lation with Hb. Similarly, the poor association between Ret-
He and reticulocyte count may be expected due to the timing
of observations. During erythropoiesis Ret-He increases ear-
lier than reticulocyte count by a few days, with the reticulocyte
count subsequently returning to normal once Hb has been
corrected. Therefore, a concurrent Ret-He and reticulocyte
count will not show a correlation unless the improved iron
status has only recently occurred.
The modest correlation between Ret-He and TSAT in our
study (r=+0.34) is in keeping with the study by Miwa et al.
[27], and strengthens the hypothesis that this combination of
biomarkers warrants further exploration independent of ferritin.
Our study demonstrated a weaker negative correlation between
Ret-He and the dose of rHuEPO (r=−0.26) than demonstrated
in an adult population [36]. Nevertheless, the direction of the
Pediatr Nephrol (2016) 31:819–826
correlation further supports the utility of Ret-He. Taken togeth-
er, prospectively testing whether patients with adequate Ret-He
who remain anemic may benefit more from increasing
rHuEPO than iron supplementation warrants consideration.
The diagnostic performance of Ret-He to detect absolute
iron deficiency anemia is superior to currently used parame-
ters and fits within the range of results demonstrated in previ-
ous adult studies. These have demonstrated an AUC between
0.657 and 0.913, sensitivities between 40 and 100 %, and
specificities between 65 and 95 % [26, 27, 30, 35]. The vari-
ability in reported Ret-He cut-off values reflects in part the
lack of an easily reproducible gold standard test. Iron bone
marrow staining, as the adult gold standard for absolute iron
deficiency, is impractical, invasive, has high inter-observer
variability, and is poorly validated in children. Using a func-
tional definition, such as a response to intravenous iron with
an increase in hemoglobin or decrease in rHuEPO require-
ment [29, 30], may be a more valid method to diagnose func-
tional iron deficiency, although this has the disadvantage of
being retrospective.
Our study has several weaknesses inherent in retrospec-
tive cohort study design, including incomplete data for
some variables. Additionally, in the absence of a uniformly
accepted definition of functional iron deficiency or the
ability to assess erythropoietic response to iron supplemen-
tation in our study, for this analysis we have used a defini-
tion including TSAT and ferritin, which as discussed likely
has inherent error.
The lack of a reliable and practical gold standard assess-
ment for iron status engenders difficulty when examining the
utility of newer biomarkers. However, future research would
be improved by a prospective design that captures the change
in Ret-He, markers of erythropoiesis and rHuEPO require-
ment following iron administration.
Conclusions
In summary, Ret-He demonstrated superiority over ferritin
and TSAT in the evaluation of iron status in anemic children
on chronic dialysis. Ret-He values of 28.9 and 27.7 pg pro-
duced the best sensitivity and specificity for the diagnosis of
absolute iron deficiency anemia and functional iron deficiency
anemia, respectively, and were within the range reported in
adult studies. The Ret-He correlations with Hb, rHuEPO, and
TSAT support prospectively testing the hypothesis that Ret-He
can be used to distinguish between iron deficiency and sub-
optimal rHuEPO dosing as competing causes for anemia in
this population. However, until such data is available, the rou-
tine incorporation of this parameter in monitoring and treat-
ment algorithms will represent an improvement on ferritin,
which should be abandoned as a measure of iron status in this
population.
Pediatr Nephrol (2016) 31:819–826
Acknowledgments We would like to acknowledge Jane Ronaldson,
renal nurse specialist at Starship Hospital for her continued data collection
efforts and exemplary care provided to our children needing dialysis.
Study approval Institutional ethical approval was obtained from the
Auckland District Health Board research review office with a waiver of
patient informed consent requirement due to the retrospective nature of
the study.
Compliance with ethical standards
Conflict of interest No funding source was required for the preparation
of this work.
The authors have no financial or ethical conflicts of interest as relate to
this manuscript.
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