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NKF-KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease
UPDATE OF HEMOGLOBIN TARGETAm.J.Kidney.Dis. 50 (3):471-530, 2007.
KDOQI AnemiaOrganization
Evidence Review Team Tufts New England Medical Center
Work Group 9 Adult Nephrologists 2 Pediatric Nephrologists 2 Hematologists 1 Nurse Practitioner 1 Dietician
CPR and CPG 2.1: Hb TargetIntroduction
The Hb target is the intended aim of ESA therapy for the individual CKD patient. In clinical practice, achieved Hb results vary considerably from the Hb target.
CPR 2.1.1Considerations
In the opinion of the work group, selection of the Hb target and selection of the Hb level at which ESA therapy is initiated in the individual patient should include consideration of potential benefits (including improvement in quality of life and avoidance of transfusion) and potential harms (including the risk of life-threatening adverse events). (Clinical Practice RECOMMENDATION)
CPR 2.1.2Selection of the Hb target
In the opinion of the work group, in dialysis and non-dialysis CKD patients receiving ESA therapy, the selected Hb target should generally be in the range of 11.0 to 12.0 g/dL. (Clinical Practice RECOMMENDATION)
CPG 2.1.3Hb targets to avoid
In dialysis and non-dialysis CKD patients receiving ESA therapy, the Hb target should not be above 13.0 g/dL. (Clinical Practice GUIDELINE - MODERATELY STRONG EVIDENCE)
Rationale: 2.1.2
Distinguishing Target Hb from Achieved Hb
Target Hb is the aim of ESA therapy
Achieved Hb is the result of ESA therapy
Achieved Hb results vary considerably from the Hb target
Safety of achieved Hb relative to 11-12 g/dL target Hb or Hb > 11 g/dL threshold is well-established
Rationale: 2.1.2
The Hb target should not be above 13.0 g/dL (Moderately Strong Recommendation)
Evidence from RCTs Considered all trials that compared Hb
target > 13.0 g/dL to lower target All these RCTs tested the hypothesis that
the higher target would prevent adverse cardiovascular events or mortality, or all cause mortality
None showed a benefit on those outcomes
Rationale: 2.1.3
Meta-Analysis
Performed by Evidence Review Team
RCTs with ≥ 6 months follow-up, no restriction on study size
Statistical model: random effects
Separated dialysis from non-dialysis CKD trials
Combined all cardiovascular disease events for analysis of cardiovascular adverse event risk
Relative mortality risk for assignment to higher treatment targets: Non-Dialysis-CKD
Rationale: 2.1.3
Relative Risk: 1.02, 95% CI 0.63-1.61
HigherHb Target
11.711.0-11.7
13.012.0-14.013.0-15.013.0-15.0
13.511.0
13.0
Relative risk of cardiovascular events for assignment to higher targets: Non-dialysis CKD
Rationale: 2.1.3
Relative Risk: 1.24, 95% CI 1.02-1.51
11.7
12.0-14.013.0-15.013.0-15.0
13.0-15.013.5
HigherHb Target
Relative mortality risk for assignment to higher treatment targets: Dialysis CKD
Rationale: 2.1.3
Relative Risk: 1.12, 95% CI 0.91-1.37
14.0
13.0-14.0
13.5-16.0
13.5-14.5
HigherHb Target
Relative risk of cardiovascular events for assignment to higher targets: Dialysis CKD
Relative Risk: 1.14, 95% CI 0.79-1.64
Rationale: 2.1.3
14.0
13.0-14.0
13.5-14.5
HigherHb Target
The Statement: Hb Target should not be above 13 g/dL
Reflects Work Group judgment The possibility to cause harm weighs
more heavily than the potential to improve quality of life and reduce the likelihood of transfusions
Moderately strong, evidence-based, clinical practice guideline
Rationale: 2.1.3
Recommended