KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target.

The Clinical Practice Guideline (CPG) and Clinical Practice Recommendations (CPRs) are designed to provide information and assist decision-making. They are not intended to define a standard of care, and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of the CPG and CPRs is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The National Kidney Foundation (NKF) makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. Specifically, all members of the Work Group are required to complete, sign, and submit a Conflict of Interest: Disclosure and Attestation form showing all such relationships that might be perceived as real or potential conflicts of interest. All affiliations are published in their entirety at the end of this document in the Work Group members' biographical sketch and are on file at the NKF. FIGURES Figure 1. Randomized controlled trials comparing lower with higher Hb target levels………. 11 Figure 2. Relative mortality risk for assignment to higher Hb treatment targets in patients with non-dialysis CKD (Stages 1-5)………………………………………………… 13 Figure 3. Relative risk of adverse cardiovascular events for assignment to higher Hb treatment target in patients with non-dialysis CKD (Stage 1-5)…………………….. 13 Figure 4. Relative mortality risk for assignment to higher Hb treatment target in CKD patients undergoing dialysis………………………………………………………… 14 Figure 5. Relative risk of adverse cardiovascular events for assignment to higher Hb treatment target in CKD patients undergoing dialysis………………………………. 2 3 The Hb target is the intended aim of ESA therapy for the individual CKD patient. In clinical 4 practice, achieved Hb results vary considerably from the Hb target. 5 6 7 2.1.1 In the opinion of the work group, selection of the Hb target and selection of the Hb 8 level at which ESA therapy is initiated in the individual patient should include 9 consideration of potential benefits (including improvement in quality of life and 10 avoidance of transfusion) and potential harms (including the risk of life-threatening 11 adverse events). (Clinical Practice RECOMMENDATION) 12 …

[1]  F. Locatelli,et al.  Novel erythropoiesis stimulating protein for treatment of anemia in chronic renal insufficiency. , 2001, Kidney international.

[2]  A. Nissenson,et al.  Randomized, controlled trial of darbepoetin alfa for the treatment of anemia in hemodialysis patients. , 2002, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[3]  S. Fishbane,et al.  Hemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin. , 2005, Kidney international.

[4]  B. Kanna,et al.  Target level for hemoglobin correction in patients with diabetes and CKD: primary results of the Anemia Correction in Diabetes (ACORD) study. , 2007, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[5]  A R Nissenson,et al.  The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. , 1998, The New England journal of medicine.

[6]  J. Lazarus,et al.  Impact of the Change in CMS Billing Rules for Erythropoietin on Hemoglobin Outcomes in Dialysis Patients , 2006, Blood Purification.

[7]  H. Krum,et al.  Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: a meta-analysis , 2007, The Lancet.

[8]  H. Burger,et al.  Normalization of hemoglobin level in patients with chronic kidney disease and anemia. , 2006, The New England journal of medicine.

[9]  A. Levin,et al.  Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy. , 2000, Kidney international.

[10]  A. Levin,et al.  Effect of early correction of anemia on the progression of CKD. , 2006, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[11]  S. Fishbane,et al.  Hemoglobin variability in epoetin-treated hemodialysis patients. , 2003, Kidney international.

[12]  M. Rudnick,et al.  Effects of recombinant human erythropoietin on renal function in chronic renal failure predialysis patients. , 1994, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[13]  D Richardson,et al.  Optimizing erythropoietin therapy in hemodialysis patients. , 2001, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[14]  G. Y. Wong,et al.  Precision of health-related quality-of-life data compared with other clinical measures. , 2007, Mayo Clinic proceedings.

[15]  K. Siamopoulos,et al.  Treating anemia early in renal failure patients slows the decline of renal function: a randomized controlled trial. , 2004, Kidney international.

[16]  R. Foley,et al.  Anaemia and mortality in haemodialysis patients: interaction of propensity score for predicted anaemia and actual haemoglobin levels. , 2006, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[17]  R. Foley,et al.  Double-blind comparison of full and partial anemia correction in incident hemodialysis patients without symptomatic heart disease. , 2005, Journal of the American Society of Nephrology : JASN.

[18]  J. Singer,et al.  Canadian randomized trial of hemoglobin maintenance to prevent or delay left ventricular mass growth in patients with CKD. , 2005, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[19]  I. Macdougall,et al.  Is early treatment of anaemia with epoetin-alpha beneficial to pre-dialysis chronic kidney disease patients? Results of a multicentre, open-label, prospective, randomized, comparative group trial. , 2007, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[20]  David Voss,et al.  Effects of early and late intervention with epoetin alpha on left ventricular mass among patients with chronic kidney disease (stage 3 or 4): results of a randomized clinical trial. , 2004, Journal of the American Society of Nephrology : JASN.

[21]  Eduardo Lacson,et al.  The effects of higher hemoglobin levels on mortality and hospitalization in hemodialysis patients. , 2003, Kidney international.

[22]  Alexander Tsertsvadze,et al.  Systematic reviews: when is an update an update? , 2006, The Lancet.

[23]  G. Guyatt,et al.  Users' guides to the medical literature: XIX. Applying clinical trial results. A. How to use an article measuring the effect of an intervention on surrogate end points. Evidence-Based Medicine Working Group. , 1999, JAMA.

[24]  G. Eknoyan,et al.  Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). , 2006, Kidney international.

[25]  C. Bartlett,et al.  Structured conversion from thrice weekly to weekly erythropoietic regimens using a computerized decision-support system: a randomized clinical study. , 2005, Journal of the American Society of Nephrology : JASN.

[26]  Y. Kawaguchi,et al.  Reversal of anemia by erythropoietin therapy retards the progression of chronic renal failure, especially in nondiabetic patients. , 1997, Nephron.

[27]  G. Beck,et al.  Association of achieved dialysis dose with mortality in the hemodialysis study: an example of "dose-targeting bias". , 2005, Journal of the American Society of Nephrology : JASN.

[28]  J. Lazarus,et al.  Effect of variability in anemia management on hemoglobin outcomes in ESRD. , 2003, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[29]  A. Christensson,et al.  A randomized controlled trial of haemoglobin normalization with epoetin alfa in pre-dialysis and dialysis patients. , 2003, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[30]  O. Djurdjev,et al.  Haemoglobin at time of referral prior to dialysis predicts survival: an association of haemoglobin with long-term outcomes. , 2006, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[31]  V. Prasad Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease , 2007 .