Anemia of chronic kidney disease: Target hemoglobin/hematocrit for patients treated with erythropoietic agents
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Section Editors
- Steve J Schwab, MD
Steve J Schwab, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- University of Tennessee Health Science Center
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
Anemia has been defined by the World Health Organization (WHO) as a hemoglobin (Hgb) concentration <13.0 g/dL for adult males and postmenopausal women and an Hgb <12.0 g/dL for premenopausal women . Based upon these criteria, nearly 90 percent of patients with a glomerular filtration rate (GFR) <25 to 30 mL/min have anemia, many with Hgb levels <10 g/dL .
Ever since the approval of recombinant human erythropoietin (epoetin alfa, EPO) by the US Food and Drug Administration (FDA), this and other erythropoiesis-stimulating agents (ESAs) have become the standard of care for the treatment of the anemia that occurs in most patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). As a result, mean Hgb and hematocrit (Hct) levels in patients with CKD, particularly those on dialysis, rose steadily through 2005 [3,4]. By 2006, 90 percent of patients maintained on chronic dialysis in the United States received ESAs, with a mean Hgb level among dialysis patients of 12.0 g/dL [4,5]; two-thirds of all patients had Hgb levels between 11 and 13 g/dL .
Anemia has also been implicated as a contributing factor in many of the symptoms associated with reduced kidney function. These include fatigue, depression, reduced exercise tolerance, dyspnea, and cardiovascular consequences, such as left ventricular hypertrophy (LVH) and left ventricular systolic dysfunction . It is also associated with an increased risk of morbidity and mortality, principally due to cardiac disease and stroke [7-10], and with an increased risk of hospitalization, hospital length of stay, and mortality in patients with predialysis CKD [11-14]. Associations, however, do not prove causality; thus, these associations may reflect underlying comorbid conditions and severity of illness that contribute to both the severity of anemia, reduced responsiveness to ESAs, and poorer outcomes.
A review of the data relating to target Hgb or Hct levels for patients with anemia due to renal disease treated with ESAs is presented here. Issues relating to erythropoietin, darbepoetin, and iron administration are presented separately. (See "Erythropoietin for the anemia of chronic kidney disease among predialysis and peritoneal dialysis patients" and "Erythropoietin for treatment of the anemia of chronic kidney disease in hemodialysis patients" and "Darbepoetin alfa for the management of anemia in chronic kidney disease" and "Iron balance in nondialysis, peritoneal dialysis, and home hemodialysis patients" and "Use of iron preparations in hemodialysis patients".)
INDICATIONS FOR TREATMENT
An overview of treatment options for anemia among dialysis and nondialysis chronic kidney disease (CKD) patients, including the relative indications for treatment with erythropoiesis-stimulating agents (ESAs) versus transfusion, is presented elsewhere. (See "Erythropoietin for treatment of the anemia of chronic kidney disease in hemodialysis patients", section on 'Indications' and "Erythropoietin for the anemia of chronic kidney disease among predialysis and peritoneal dialysis patients", section on 'Whom to treat and target hemoglobin level'.)
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- INDICATIONS FOR TREATMENT
- TARGET LEVELS
- CLINICAL PRACTICE GUIDELINES
- POPULATION STUDIES
- RANDOMIZED TRIALS AND SYSTEMATIC REVIEWS
- Systematic reviews
- Normal Hematocrit Trial
- Trials in chronic kidney disease patients not yet on dialysis
- Effect upon left ventricular hypertrophy
- Quality of life
- Adverse effects
- ESA doses, target hemoglobin levels, and response to ESA
- SUMMARY AND RECOMMENDATIONS