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Ovid: Oxford Handbook of Dialysis

Editors: Levy, Jeremy; Morgan, Julie; Brown, Edwina Title: Oxford Handbook of Dialysis, 2nd Edition Copyright ©2004 Oxford University Press > Table of Contents > Part 8 – Complications of ESRD: anaemia > Erythropoietin: target haemoglobin Erythropoietin: target haemoglobin

  • Target Hb remains controversial.
  • Tends to be governed by economic factors; there is no randomized clinical trial data yet to support higher Hb levels.
  • Current UK Renal Association Hb target is >10.0 g/dl and the European best practice guideline is a target Hb of 11.0 g/dl.
  • Patients with angina may get less symptoms at higher Hb levels.
  • There is anecdotal evidence that patients with heart failure have less symptoms and improved cardiac function with Hb levels corrected to normal levels.
  • Fears about increased vascular access thrombosis with higher Hb levels have not been proven.
  • Hb levels in a dialysis population on EPO follow a normal distribution. Therefore in order to achieve 80% of patients having a Hb higher than the target, a dialysis unit must aim for a higher Hb level overall. To achieve >80% of patients with Hb >11g/dl, it is necessary to aim for a level of 11–12 g/dl (33–36% Hct).

This degree of correction of anaemia improves survival, causes regression of ventricular hypertrophy, improved quality of life, exercise capacity, and cognitive function. More recently, higher values of Hb have been associated with better cognitive function, better quality of life, further improvement in exercise capacity, and in some patients prevention of progressive left ventricular dilatation. However, the normal Hct cardiac trial randomized patients with heart disease to normal or usual Hct (and achieved Hct of 42% vs 30%) and was stopped early because of a trend to increased mortality in the normal Hct group. This result was confounded by a decrease in mortality in both arms with increasing Hct. The Canadian study of normalization of Hb in HD patients with asymptomatic cardiomyopathy (Hb 11 or 13.5 g/dl) showed improved quality of life with higher Hb, and some cardiac benefits. Ideal target Hb for maximal benefit therefore remains to be defined.

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