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Anaemia management and mortality risk in chronic kidney disease

Nature Reviews Nephrology volume 9, pages 291–301 (2013)Cite this article

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Abstract

Renal anaemia is a frequent complication in patients with chronic kidney disease (CKD). Severe anaemia (haemoglobin <90 g/l) is associated with increased risks of mortality and cardiac complications, such as left ventricular hypertrophy and cardiovascular disease, and impaired quality of life. Randomized controlled trials have tested the hypothesis that increasing haemoglobin level using erythropoiesis-stimulating agents (ESAs) lowers these risks and improves quality of life. Use of ESAs to normalize haemoglobin levels (to ≥130 g/l) versus the partial correction of anaemia (to haemoglobin levels of 90–110 g/l) has repeatedly been shown to have no cardiac benefit and to be associated with no incremental improvement in outcomes and quality of life (except fatigue), but has been shown to be associated with an increased risk of cardiovascular events and death. Use of more-intense iron dosing has been proposed in order to reduce ESA dosing but liberal intravenous iron therapy is also associated with complications, and its long-term safety has not yet been adequately investigated. For patients with CKD on dialysis, US medication labels recommend administering ESAs at doses sufficient to avoid transfusions, whereas European and Canadian labels recommend targeting haemoglobin levels of 100–120 g/l and 110–120 g/l, respectively. Treatment of anaemia to haemoglobin levels of 90–110 g/l in patients with CKD accomplishes what we want—a reduced need for transfusions and possible reductions in fatigue, while avoiding high doses of ESA or iron in order to achieve a specific haemoglobin goal.

Key Points

  • Anaemia is a frequent complication in patients with chronic kidney disease (CKD) and is a risk factor for morbidity, mortality and impaired quality of life

  • In contrast to observational datasets and retrospective data analyses, multicentre trials showed that higher haemoglobin target levels and/or higher erythropoiesis-stimulating agent (ESA) doses are associated with increased risks in patients with CKD

  • Anaemia management in CKD has moved from using haemoglobin level as a surrogate end point to use of more patient-relevant clinical outcomes while using the lowest possible ESA dose necessary for transfusion avoidance

  • Naturally occurring near-normal haemoglobin level does not increase the risk of morbidity and mortality in patients with CKD

  • The higher the ESA dose used for achieving target haemoglobin concentrations in CKD patients who respond poorly to ESA treatment, the worse the outcome

  • Beneficial effects of intravenous iron therapy should be weighed against potential harms and hazards associated with its excessive use

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  1. Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Währinger Gürtel 18–20, Vienna, A-1090, Austria

    Walter H. Hörl

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Walter H. Hörl declares associations with the following companies: Amgen (speakers' bureau), Sandoz (consultant), Hexal (consultant, speakers' bureau), Fresenius (speakers' bureau, research support), Vifor (consultant, speakers' bureau, grant/research support), Medice (speakers' bureau), Abbott (speakers' bureau) and Takeda (consultant).

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Hörl, W. Anaemia management and mortality risk in chronic kidney disease. Nat Rev Nephrol 9, 291–301 (2013). https://doi.org/10.1038/nrneph.2013.21

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