Abstract: In 2019, the New England Journal of Medicine published the results of the PIVOTAL (Proactive IV Iron Therapy in Haemodialysis Patients) study “Intravenous Iron in Patients Undergoing Maintenance Hemodialysis”, which showed the efficacy and safety of highdose intravenous iron in maintenance hemodialysis patients and attracted much attention. However, the authors put forward several key issues to discuss with experts and colleagues in combination with the indepth study, thinking of a number of previous and recent clinical studies and related guidelines. The authors concluded that there are still many controversies about the efficacy and safety of highdose intravenous iron in maintenance hemodialysis patients, which need to be confirmed by more researches with high grade evidence. At present, individualized iron supplementation should be used in clinical application, in the meantime, the monitoring of organ iron overload should be strengthened to avoid iron overload. Highdose intravenous iron should still be used with extreme caution in clinical practice.