International

Renal Anaemia in the news

Relatively high hemoglobin levels boost survival in hemodialysis patients

• 09 March 2009
• Reuters Health

By Michelle Rizzo

NEW YORK (Reuters Health) - In chronic hemodialysis patients, long-term survival is favorably affected by a relatively high hemoglobin level and moderate intravenous iron administration, according to findings published in the current online issue of BMC Nephrology.

Anemia in hemodialysis patients "is due, in part, to deficiencies of erythropoietin (EPO) and iron, both of which are correctible," lead author Dr. Victor E. Pollak, of MIQS Inc. in Boulder, Colorado, explained in an interview with Reuters Health. "How far the anemia is corrected has been a very controversial subject."

"Several studies have put forward the view that correcting the anemia to above a reasonable, but in my view modest, level of 12 grams per deciliter (14 is normal) was associated with adverse effects on patient survival," the author continued. "As a result of these studies, the FDA issued warnings about the practice, and the Center for Medicare and Medicaid Services (CMS) guidelines discouraged doctors from raising the hemoglobin to above 12 grams per deciliter."

Dr. Pollak and colleagues studied 1774 patients receiving hemodialysis at three units in New York between January 1, 1998, and December 31, 2006. Median survival was 789 days. The median epoetin-alpha dose was 18,162 units/week, and the median amount of IV iron administered was 301.2 mg/month. Median hemoglobin was 116.1 g/L, median transferrin saturation was 29.76%, and median serum ferritin was 526.2 mcg/L.

"Survival was better the higher the hemoglobin," the researchers report, with the best survival in patients with mean values above 120 g/L. Survival was worst in patients with transferrin saturation at or below 16% and serum ferritin at or below 100 mcg/L. Survival was best with transferrin saturation above 25% and serum ferritin above 600 mcg/L.

For IV iron, survival was best with 1 to 202 mg/month, slightly worse with 202 to 455 mg/month, and worst with no IV iron. Survival was only slightly better for those who received IV iron >455 mg/month compared to the no IV iron group. While the effect of epoetin-alpha on survival was weak, it had a statistically significant interaction with IV iron.

"Patients are much better off when they are not anemic, as long as attention is paid to ensuring that they are iron sufficient," Dr. Pollak said in the interview. "Patients do best when they receive low to modest rather than large amounts of EPO," he noted. "Moderate amounts of iron are essential for their survival."

"Guidelines that doctors use for management of anemia, including those promulgated by CMS, need to be reassessed in the light of these data," Dr. Pollak added.

"'Controlled clinical trials' used as a basis for setting the standard of care addressed the dose of EPO but did not consider whether the patients were iron deficient," he said. "Guidelines developed without recognizing this important flaw in the studies naturally conveyed information not optimal for care of patients."

BMC Nephrol 2009.