| Theme | Guideline for CKD-related anemia -- looking back twice's revision | |
|---|---|---|
| Title | Suitable Hb levels for initiating renal anemia treatment | |
| Publish Date | 2017/02 | |
| Author | Koji Mitsuiki | Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital |
| Author | Hideki Hirakata | Fukuoka Renal Clinic |
| [ Summary ] | The Japanese Society for Dialysis Therapy (JSDT) has presented revised clinical guidelines for anemia treatment for CKD patients, pre-dialysis, hemodialysis (HD) and peritoneal dialysis (PD), in 2004, 2008 and 2015. After the publication of four large clinical studies conducted in the US and Europe, the Normal-Hematocrit Trial, CREATE, CHOIR and TREAT, high doses of erythropoiesis-stimulating agent (ESA) aiming to achieve near normal levels of hemoglobin (Hb) have been prohibited due to "cardiotoxicity". The KDIGO has lowered suggested target Hb levels during ESA treatment to 10 g/dL and set iron administration as a first-line therapy for the ESA-naïve patients. However, they did not clearly demonstrate the Hb levels for starting ESA. In Japan, the situation is somewhat different. We have never experienced the achievement of near normal levels of Hb or any apparent cardiotoxicity from ESAs. Although the safety issue related to ESA use has not been fully elucidated, it should be given to patients for whom a sustained-low Hb with sufficient iron levels is expected to be harmful. The timing for starting ESA is usually assessed by examination Hb levels. However, there is no consensus concerning critical levels of Hb when it is left untreated. From a clinical point of view, it is reasonable to start ESA when Hb levels fall below 10 to 11 g/dL. Target levels should be maintained for several months after confirming efficient iron status. However, we are not sure whether there is any difference between the Hb levels of ESA in non-dialysis CKD patients, PD patients or HD patients. In HD patients, we should be cautious of Hb fluctuations induced by HD procedures. |
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