The optimal hemoglobin in dialysis patients - A critical review

The introduction of recombinant human erythropoietin treatment has been one of the most important advances in the treatment of dialysis patients and others with chronic kidney disease (CKD). Treatment of CKD anemia has been shown to reduce the need for blood transfusions and to improve quality of life. However, the target hemoglobin level in treating patients is currently controversial. This is because of the recent publication of two randomized controlled studies in nondialysis CKD patients, the CREATE and CHOIR studies, as well as an accompanying meta-analysis. These studies demonstrate increase risk for death and cardiovascular complications when aiming for a hemoglobin (Hgb) level of > 12 g/dl. In light of this new data, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative anemia guidelines are being revised. The Food and Drug Administration has issued a Black Box warning and indicated that hemoglobin levels do not exceed 12 g/dl. While observational data suggest a benefit for higher hemoglobin levels, these studies have limitations because of their retrospective design and the potential effect of confounding factors. Hence, reliance on observational studies to guide CKD anemia treatment is a potentially flawed and hazardous process. In this editorial we propose that the current literature does not support an upper Hgb target above 12 g/dl. We also suggest that the current reimbursement system for erythropoiesis stimulating agent treatment potentially encourages unsafe overtreatment.