High hemoglobin levels in CKD anemia patients linked to higher death and cardiovascular risks.


Achieving high hemoglobin levels in patients with CKD anemia may confer no cardiovascular benefit and could even increase the risk of death and cardiac problems, according to two studies published in the New England Journal of Medicine (2006;355:2071-2084;2085-2098).

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In the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) trial, Ajay Singh, MD, and his colleagues randomly assigned patients with CKD anemia to receive doses of epoetin alfa to achieve either a target hemoglobin value of 11.3 g/dL (717 patients) or 13.5 g/dL (715 patients).


Findings showed that compared with the low-hemoglobin group, the high-hemoglobin group experienced a 34% greater risk of death, MI, hospitalization for congestive heart failure (without renal replacement therapy), or stroke, with no incremental improvement in quality of life. A significantly higher proportion of patients in the high-hemoglobin group experienced at least one serious adverse event (see chart).


The two groups were similar with respect to the types of serious adverse events, except for heart failure, which occurred more frequently in the high-hemoglobin group. Death and hospitalization for heart failure accounted for 74.8% of the untoward events.


“Since our study showed no apparent additional benefit in quality of life, and since the cost of epoetin alfa treatment increases with higher doses, we believe that the use of a high-target hemoglobin level provides no cost benefit for either patients or payers in this population, even before considering risk,” the authors wrote. Dr. Singh, who is clinical chief of the renal division at Brigham and Women’s Hospital in Boston, also presented the findings at the American Society of Nephrology’s annual meeting (Renal Week) in San Diego.


A panel of the Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation recommended in 2000 that the tar-get level of hemoglobin in CKD patients should be 11-12 g/dL, the researchers noted. A recent update of those guidelines raised the target range to 11-13 g/dL, “with the increase in the upper limit justified on the basis of a potential improvement in the patient’s quality of life.”