A target hemoglobin concentration of less than 12 g/dL appears to be optimal, according to findings of a meta-analysis.
The optimal target hemoglobin level in erythropoietin-treated patients with chronic renal disease has long been a source of controversy. Current guidelines recommend that hemoglobin be maintained above 11 g/dL, but recent studies have suggested that higher target levels may be associated with an increase in major cardiovascular events (Journal Watch Nov 15 2006).
Researchers conducted a meta-analysis of nine randomized controlled trials comparing low (<12 g/dL) and high (>12 g/dL) hemoglobin targets in 5143 patients with anemia caused by chronic renal disease who were treated with erythropoietin for at least 12 weeks. After 12 to 48 months of follow-up, patients with higher hemoglobin targets had significantly increased risks for all-cause mortality (relative risk, 1.17), arteriovenous access thrombosis (RR, 1.34), and uncontrolled blood pressure (RR, 1.27). The risk for myocardial infarction was similar in the two groups.
Comment: Based on an analysis of composite cardiovascular outcomes in three trials, editorialists argue that "higher hemoglobin target concentrations increase mortality via cardiovascular endpoints." Whether the increase in adverse outcomes in the high-target group is attributable to the higher hemoglobin concentration itself or to some other effect of the higher erythropoietin dose required to reach that concentration is not clear. The editorialists urge that a hemoglobin target of less than 12 g/dL be adopted for patients with chronic renal disease and that ongoing studies of this issue be discontinued.
— Bruce Soloway, MD
Published in Journal Watch General Medicine February 15, 2007
Phrommintikul A et al. Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: A meta-analysis. Lancet 2007 Feb 3; 369:381-8.