Correcting Anemia in Patients with Chronic Kidney Disease

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.