Kidney Disease: Improving Global Outcomes (KDIGO)

Rationale for Guideline Hemoglobin Targets

Hemoglobin Targets

Contribution from European Best Practice Guidelines Committee

The current 2004 version of the European Best Practice Guidelines recommend:

A target haemoglobin of > 11 g/dl in all patients.
An exact target level > 11 g/dl should be determined for the individual patient.
In HD patients, pre-dialysis Hb > 14 g/dl are not desirable.
In patients severe cardiovascular disease (NYHC Class III or above), Hb > 12 g/dl is not recommended unless ongoing symptoms dictate otherwise.
In patients with diabetes, especially those with peripheral vascular disease, a cautious approach to raising Hb > 12 g/dl is recommended.
Patients with chronic hypoxaemic pulmonary disease may benefit from a higher Hb target.

Rationale: Physiological principles suggest that normalising Hb (12-16 g/dl) should be the goal. However in HD patients there are concerns that normal Hb may lead to increased in thrombotic complications¹. Haemoconcentration during dialysis could lead to dangerously high Hb post-dialysis if pre-dialysis Hb is > 14 g/dl.

There is evidence that increasing Hb to the range 10-11 results in improved outcome².

There is evidence that Hb>12 is harmful in patients with diabetes or severe CV disease^1,2.
In patients without diabetes or severe CV disease, there is weak evidence that Hb>12 is beneficial and no evidence that it is harmful. Despite potential or possible benefits in raising Hb>12 in patients without diabetes or severe CV disease, it may not always be cost-effective.

References:

Besarab A, Bolton WK, Browne JK et al. 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 1998; 339: 4–590
Strippoli GF, Manno C, Schena FP, Craig JC. Haemoglobin and haematocrit targets for the anaemia of chronic renal disease (Cochrane review). Cochrane Database Syst Rev 2003;

Prepared on behalf of the European Best Practice Guidelines Committee by James Tattersall (Sub-group Chairman)