New Hemoglobin Target Levels for Chronic Kidney Disease

In chronic kidney disease (CKD), the preferred hemoglobin target should be 9.0 to 12.0 g/dL, suggests the results of a systematic review and meta-analysis.

“Treatment of anemia in … CKD with erythropoietin-stimulating agents (ESAs) is commonplace,” write Fiona M. Clement, PhD, from the University of Calgary in Alberta, Canada, and colleagues. “The optimal hemoglobin treatment target has not been established. A clearer understanding of the health-related quality of life (HQOL) impact of hemoglobin target levels is needed.”

The reviewers searched the literature from 1966 through December 2006 for all randomized controlled trials (RCTs) of ESA treatment in patients with anemia associated with CKD. Inclusion criteria were sample size of 30 or more anemic adults with CKD, comparison of epoetin (alfa and beta) or darbepoetin versus control, and reporting of HQOL with use of a validated measure. A systematic review and meta-analysis was performed of all available 36-item short-form (SF-36) RCT data on HQOL for patients treated with low to intermediate (9.0 – 12.0 g/dL) and high hemoglobin target levels (> 12.0 g/dL).

Of 231 articles identified, 11 studies were eligible for inclusion, of which 9 used the SF-36. However, reporting of SF-36 data was generally incomplete. For different domains of the SF-36, there were statistically significant changes in physical function (weighted mean difference [WMD], 2.9; 95% confidence interval [CI], 1.3 – 4.5), general health (WMD, 2.7; 95% CI, 1.3 – 4.2), social function (WMD, 1.3; 95% CI, ?0.8 to 3.4), and mental health (WMD, 0.4; 95% CI, 0.1 – 0.8) domains. None of these changes were thought to be clinically important.

“Our study suggests that targeting hemoglobin levels in excess of 12.0 g/dL leads to small and not clinically meaningful improvements in HQOL,” the review authors write. “This, in addition to significant safety concerns, suggests that targeting treatment to hemoglobin levels that are in the range of 9.0 to 12.0 g/dL is preferred.”

“Erythropoietin-stimulating agents are an important aspect of treatment for patients with CKD, especially for those undergoing hemodialysis or who are at risk of requiring blood transfusion without treatment,” the review authors conclude. “The cited goal of treatment to a higher hemoglobin target level is often to improve HQOL. However, our systematic review revealed a weak evidence base in support of that strategy, with poorly reported data and only 2 RCTs that examined HQOL as the primary study end point.”

Arch Intern Med. 2009;169:1104-1112.