Rationale for Guideline Hemoglobin Targets

Hemoglobin Targets

Contribution from UK Renal Association Clinical Practice Guidelines Committee

The current 3rd edition of the Renal Association “Standards” states:

Patients with chronic renal failure (CRF) should achieve a haemoglobin of 10 g/dl within six months of being seen by a nephrologists.

In the 4th edition (now called the Renal Association Clinical Practice Guidelines), this statement has been changed to:

Patients with CKD should achieve a haemoglobin of 10.5-12.5 g/dl. At present it is not deemed health economically viable to aim at higher population haemoglobin concentrations among patients receiving dialysis.

Rationale for modified guideline: The main reason to treat anaemia in haemodialysis patients is to improve symptoms, since no robust studies to date have shown benefits in hard clinical outcomes such as mortality rates. However, evidence from randomised controlled trials has reinforced the value of partial correction of anaemia in improving quality of life.

The health economics of anaemia therapy using erythropoiesis-stimulating agents (ESAs) has recently been subject to a review by the UK National Institute of Clinical Excellence (NICE), a government organisation that assesses new and expensive healthcare technologies¹. Their report concludes that treating to a target haemoglobin of 11-12g/dl is cost effective in haemodialysis patients. In a US study the incremental cost per QALY of achieving a target haemoglobin of 12.0-12.5 g/dl versus 11.0-12.0g/dl was $613,015. An additional $828,215 per additional QALY gained was required to achieve a target haemoglobin of 14g/dl versus 12.0-12.5g/dl^1,2.

To put this guideline into current context, the Eighth UK Renal Registry Report published in December 2005³, which provides audit data from over 85% of renal units in England and Wales, suggests that such levels are achievable. The mean haemoglobin captured in this audit was 11.7g/dl (SD 1.6g/dl) with 85% compliance with a haemoglobin concentration of >10g/dl and 68% compliance with a haemoglobin >11.0g/dl.

Thus in the absence of data suggesting that higher levels of haemoglobin are beneficial and in the light of the health economics analysis, a target haemoglobin range of 10.5 to 12.5 g/dl is considered optimal, at least at the present time.

References:

1. National Collaborating Centre for Chronic Conditions, Royal College of Physicians. Guideline on Anaemia management in chronic kidney disease. 2006. National Institute for Clinical Excellence.
2. Tonelli M, Winkelmayer WC, Jindal KK, Owen WF, Manns BJ. The cost-effectiveness of maintaining higher hemoglobin targets with erythropoietin in hemodialysis patients. Kidney Int. 2003; 64: 295-304
3. UK Renal Registry. UK Renal Registry Report; The Eighth Annual Report. 8. 2005.

Prepared on behalf of the UK Renal Association Clinical Practice Guidelines Committee by Donald Richardson and David Wheeler (Chairman).