Physiological levels of Haemoglobin increase mortality in CKD?

Risk for all-cause mortality was significantly higher in patients with anemia caused by chronic kidney disease (CKD) who were treated with erythropoiesis-stimulating agents (ESAs) to higher rather than lower hemoglobin targets, according to a meta-analysis of 9 randomized controlled trials and more than 5000 patients.

The study, (published 3rd February 2007 in Lancet), also found that patients in the higher hemoglobin-target group were at increased risk for arteriovenous access thrombosis and poorly controlled hypertension.

"The most important of our findings is the significant increase in the risk of all-cause mortality seen when a target hemoglobin concentration of 120 to 160 g/L is achieved," despite this being within the normal physiologic range, the researchers from Monash University in Melbourne in Australia said.

The Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta (CREATE) and the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) also raised this issue.

Take note that there is another study coming up ....The Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT), which is investigating darbepoetin. This will provide further insight into optimal target levels.

So how do we apply this in clinical practice???

The editorialists conclude: "The question has been answered: higher hemoglobin-target concentrations increase mortality via cardiovascular end points. Partial, rather than complete correction of anemia is appropriate, although commercially less attractive, and it is time to move on."

Dr. Strippoli said: "Treat patients with CKD to a hemoglobin target of 100 to 120 g/L; if patients have severe cardiopathy, treat them to a hemoglobin target of 100 to 105 g/L."

"First, hemoglobin-target trials should be stopped, or their aims need to be strongly reassessed; second, a trial of different doses of erythropoietin is needed, because what is causing harm to the patients is probably that many of them do not respond to these drugs properly and higher doses are used."