Anemia of chronic kidney disease: When normalcy becomes undesirable

• Published in: Cleveland Clinic journal of medicine Vol. 75; no. 5; pp. 353 - 356
• Main Authors: Demirjian, Sevag G, Nurko, Saul
• Format: Journal Article
• Language: English
• Published: United States Cleveland Clinic 01-05-2008
• Subjects: Anemia - drug therapy; Anemia - etiology; Antineoplastic Agents - adverse effects; Erythropoiesis - drug effects; Erythropoietin - adverse effects; Erythropoietin - biosynthesis; Erythropoietin - therapeutic use; Hemoglobins - analysis; Humans; Kidney Failure, Chronic - complications; Kidney Failure, Chronic - drug therapy; Neoplasms - drug therapy; Receptors, Erythropoietin - drug effects; Reference Values; Renal Dialysis; Risk Factors; United States; United States Food and Drug Administration; United States
• ISSN: 0891-1150; 1939-2869
• DOI: 10.3949/ccjm.75.5.353

In patients with chronic kidney disease and renal failure, hemoglobin levels have been rising in parallel with more intensive
use of erythropoiesis-stimulating agents (ESAs). However, several recent studies indicate that raising hemoglobin to normal
levels with ESAs can be too much of a good thing. Compared with partial correction, normalization of hemoglobin did not improve
outcome, and it may have led to more frequent adverse events. The US Food and Drug Administration (FDA) now recommends a hemoglobin
goal in the range of 10 to 12 g/dL.
KEY POINTS
ESAs reduce the need for blood transfusions and possibly improve quality of life.
It is unclear if higher hemoglobin levels per se actually caused the adverse events in these trials. Event rates were highest
in patients who responded poorly to ESAs.
We concur with the FDA’s recommendation that the hemoglobin level be raised to no higher than 12 g/dL with ESAs in patients
with chronic kidney disease or renal failure.
Transient excursions of the hemoglobin level above 12 g/dL should not be a cause for panic. Rather, the next ESA dose should
be reduced.