Treatment goals for anemia in progressive kidney disease
What are the treatment goals for anemia in a patient with progressive kidney disease?
The treatment goals for anemia in a patient with progressive kidney disease are based on several clinical trials.
Three clinical trials have been performed to evaluate the effect of anemia correction with ESAs on clinical outcomes such as death, congestive heart failure, myocardial infarction, and stroke.
Two clinical trials enrolled a wide range of patients with CKD and anemia, randomly assigning them to treatment for correction of their anemia to hemoglobin of approximately 13 versus hemoglobin of approximately 11.
Although one study failed to demonstrate any benefit or harm when the two arms were compared, the other demonstrated worse outcomes in the group randomized to the higher hemoglobin level.
Finally, a trial randomly assigning patients to receive darbepoetin to achieve a target hemoglobin of 13 g/dL as compared with placebo (i.e., no anemia correction) failed to demonstrate a difference in cardiovascular outcomes or mortality between the two arms.
However, it is noteworthy that this trial did demonstrate a significantly increased risk of stroke in the arm receiving active treatment with the ESA. In addition, there was an increase in cancer-related deaths in patients with a prior history of cancer.
The treatment goal recommended by the US Food and Drug Administration (FDA) for ESAs is to consider starting ESA therapy when the hemoglobin is <10 g/dL if the rate of hemoglobin decline indicates the likelihood of requiring a red blood cell transfusion and a reduction in alloimmunization- and transfusion-related risks is the goal.
In addition, the previously mentioned trials have demonstrated an increased risk of adverse cardiovascular events when hemoglobin >11 g/dL, and the FDA now specifies that ESA dosing should be reduced or stopped if the Hb level exceeds 11 g/dL.
The relative benefit to quality of life as compared with the increased risk of cardiovascular events, particularly stroke, should be considered on a case-by-case basis.
