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Correcting Anemia in Patients with Chronic Kidney Disease

Two new randomized trials indicate that anemia should not be fully corrected in such patients.

The optimal target hemoglobin level for anemic patients with chronic kidney disease (CKD) is controversial. Two new randomized trials, both supported by makers of erythropoietin and both conducted in nondialyzed CKD patients, address this issue.

U.S. researchers enrolled 1432 patients with estimated glomerular filtration rates of 15–50 mL/min/1.73m² and hemoglobin levels <11 g/dL. Patients were assigned to a high-hemoglobin group (target, 13.5 g/dL) or a low-hemoglobin group (target, 11.3 g/dL); both groups received epoetin alfa in doses needed to achieve their targets. The trial was stopped after a mean follow-up of 16 months, when the primary outcome (death, myocardial infarction, hospitalization for heart failure, or stroke) had occurred more frequently in the high-hemoglobin group than in the low-hemoglobin group (17.5% vs. 13.5%, P=0.03). Quality-of-life scores were similar in the two groups.

In an international study, researchers enrolled 603 patients with estimated glomerular filtration rates of 15–35 mL/min/1.73m² and hemoglobin levels between 11 and 12.5 g/dL. Patients were assigned to a high-hemoglobin group with epoetin beta started immediately (target, 13–15 g/dL) or to a low-hemoglobin group with epoetin beta started only when the hemoglobin decreased to <10.5 g/dL. During an average follow-up of 3 years, the likelihood of a first cardiovascular event was nonsignificantly higher in the high-hemoglobin group than in the low-hemoglobin group (19.3% vs. 15.6%, P=0.20). High-hemoglobin patients were more likely than low-hemoglobin patients to initiate dialysis during the study. Quality-of-life scores were higher in the high-hemoglobin group during the first year, but differences narrowed thereafter.

Comment: These findings indicate that anemia should not be fully corrected in patients with chronic kidney disease. A guideline from the National Kidney Foundation states that "In patients with CKD, Hb should be 11.0 g/dL or greater" and that "there is insufficient evidence to recommend routinely maintaining Hb levels at 13.0 g/dL or greater" in patients receiving epoetin. We now have evidence suggesting that a 13.0 g/dL target is too high.

— Allan S. Brett, MD

Published in Journal Watch General Medicine November 15, 2006

Citation(s):

Singh AK et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 2006 Nov 16; 355:2085-98.

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• Medline abstract (Free)

Drüeke TB et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 2006 Nov 16; 355:2071-84.

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• Medline abstract (Free)

Remuzzi G and Ingelfinger JR. Correction of anemia — Payoffs and problems. N Engl J Med 2006 Nov 16; 355:2144-6.

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• Medline abstract (Free)