Rationale for Guideline Hemoglobin Targets
Hemoglobin Targets
Contribution from the Canadian Society of Nephrology Clinical Practice Guidelines Committee
CSN Guidelines Statement extracted from the first edition (1999):
The target hemoglobin during erythropoietin therapy is 110 to 120 g/L for both adult males and adult females.
Rationale in 1999: The optimal physiologic hemoglobin in the ESRD population has not been established. However, in patients with a hemoglobin < 100 g/L, there is evidence of deterioration in left ventricular hypertrophy, cerebral function, and quality of life (1,2). Patients whose hemoglobin is increased to > 100 g/L receive documented reduction in left ventricular mass toward normal. Significant increases in physical function of 2.0 points (SF-36) are achieved with each increase of 10 g/L in hemoglobin to 140 g/L (3). Patients with myocardial ischemia related to atherosclerosis or peripheral vascular ischemia related to diabetic (or other) vascular disease may benefit from a higher hemoglobin. However, using erythropoietin and intravenous iron to achieve a hemoglobin of 130 to 150 may be associated with increased mortality in patients with clinically evident congestive heart failure or ischemic heart disease (3). Therefore, patients’ hemoglobin should usually not plateau below 100 g/L or above 130 g/L. Accounting for fluctuations in the hemoglobin resulting from both laboratory and physiologic factors, if 115 g/L is used as a target hemoglobin, 96% of patients will have their hemoglobin maintained between 110 and 120 g/L.
References:
- Canadian Erythropoietin Study Group: Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Br Med J 300: 573–578, 1990
- Laupacis A: Changes in quality of life and functional capacity in hemodialysis patients treated with recombinant human erythropoietin. Semin Nephrol 10: 11–19, 1990
- Besarab A, Bolton WK, Browne JK, Egrie JC, Nissenson AR, Okamoto DM, Schwab SJ, Gooodkin DA: The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med 339: 584–590, 1998
Prepared on behalf of the CSN Guideline Committee by Bruce Culleton
