In the contemporary era of erythropoiesis-stimulating agents (ESAs) and new anemia treatments, measuring health-related quality of life (HRQoL) and a focus on the individual patient remain important, Fredric O. Finkelstein, MD, and Susan H. Finkelstein, MSW, of Yale University in New Haven, Connecticut, discussed in a recent review published in Advances in Chronic Kidney Disease.

Studies demonstrate that treatment of anemia in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) improves their HRQoL, primarily in the domains of vitality/energy and physical functioning. CHOIR (Correction of Hemoglobin and Outcomes in Renal Insufficiency), CREATE (Cardiovascular Risk Reduction by Early Anemia Treatment with Epoetin Beta), and TREAT (Trial to Reduce Cardiovascular Events with Aranesp Therapy) – 3 important randomized trials of ESA therapy – each confirmed the benefit of treatment in these domains.

According to the reviewers, the most useful HRQoL instruments are the physical functioning and energy/vitality domains of the Short Form 36 (SF-36), Functional Assessment of Cancer Therapy (FACT)-Fatigue questionnaire, the physical symptoms and fatigue domains on the Kidney Disease Questionnaire (KDQ) questionnaire, and fatigue questionnaires recommended by the Patient-Reported Outcomes Measurement Information System.

Evidence shows that substantial improvements in vitality/energy and physical functioning occur when hemoglobin levels are raised from less than 9 g/dL to 10 to 12 g/dL, with limited additional improvements above 12 g/dL. The Kidney Disease Improving Global Outcomes (KDIGO) approach is reasonable for the routine use of ESAs for CKD and ESRD patients, according to the authors. How ESAs themselves influence HRQoL, independent of their effect on anemia, also needs to be considered, they wrote.

Given that symptom burden and response to anemia treatment vary by patient, the reviewers emphasized that hemoglobin targets should be individualized – particularly as nephrology care moves to a patient-centered care model.

“In other words, rather than simply applying standardized algorithms for anemia treatment for all patients, consideration needs to be given assessing the potential benefits of anemia treatment on the individual patient, incorporating routine assessments of HRQOL into standard routine patient care.”

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Reference

Finkelstein FO, Finkelstein SH. The impact of anemia treatment on health-related quality of life in patients with chronic kidney disease in the contemporary era. Adv Chronic Kidney Dis. 2019;26:250-252. doi:10.1053/j.ackd.2019.04.003