Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement

doi:10.1093/NDT/GFT033

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Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement

Journal Article•DOI•

Kidney Disease: Improving Global Outcomes guidelines on anaemia management in chronic kidney disease: a European Renal Best Practice position statement

Francesco Locatelli, Peter Bárány¹, Adrian Covic, Angel L.M. de Francisco, Lucia Del Vecchio, David Goldsmith², Walter H. Hörl³, Gérard M. London⁴, Raymond Vanholder, Wim Van Biesen - Show less +6 more•Institutions (4)

Karolinska Institutet¹, HealthPartners², Medical University of Vienna³, French Institute of Health and Medical Research⁴

01 Jun 2013-Nephrology Dialysis Transplantation (Oxford University Press)-Vol. 28, Iss: 6, pp 1346-1359

TL;DR: The group concentrated only on those guidelines which the group considered worth amending or adapting, and all guidelines not specifically mentioned are fully endorsed.

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Abstract: Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anaemia in CKD patients. These guidelines addressed all of the important points related to anaemia management in CKD patients, including therapy with erythropoieis stimulating agents (ESA), iron therapy, ESA resistance and blood transfusion use. Because most guidelines were ‘soft’ rather than ‘strong’, and because global guidelines need to be adapted and implemented into the regional context where they are used, on behalf of the European Renal Best Practice Advisory Board some of its members, and other external experts in this field, who were not participants in the KDIGO guidelines group, were invited to participate in this anaemia working group to examine and comment on the KDIGO documents in this position paper. In this article, the group concentrated only on those guidelines which we considered worth amending or adapting. All guidelines not specifically mentioned are fully endorsed.

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Journal Article•DOI•

Targeting Hypoxia-Inducible Factors for the Treatment of Anemia in Chronic Kidney Disease Patients

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Francesco Locatelli, Steven Fishbane, Geoffrey A. Block, Iain C. Macdougall

07 Mar 2017-American Journal of Nephrology

TL;DR: Results from clinical studies of a number of HIF prolyl hydroxylase inhibitors are increasingly available and provide support for the continued evaluation of the risk-benefit ratio of this novel therapeutic approach to the treatment of anemia in CKD.

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Abstract: Background: Anemia, a common complication of chronic kidney disease (CKD), has previously been attributed primarily to decreased production of erythropoietin. Mor

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800 citations

Journal Article•DOI•

Oxidative stress in chronic kidney disease.

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Kristien Daenen¹, Kristien Daenen², Asmin Andries², Djalila Mekahli², Ann Van Schepdael², François Jouret³, Bert Bammens² - Show less +3 more•Institutions (3)

Sahlgrenska University Hospital¹, Katholieke Universiteit Leuven², University of Liège³

01 Jun 2019-Pediatric Nephrology

TL;DR: The potential role of various antioxidants and pharmacological agents, which may represent potential therapeutic targets to reduce OS in both pediatric and adult CKD patients, are discussed.

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Abstract: Oxidative stress (OS), defined as disturbances in the pro-/antioxidant balance, is harmful to cells due to the excessive generation of highly reactive oxygen (ROS) and nitrogen (RNS) species. When the balance is not disturbed, OS has a role in physiological adaptations and signal transduction. However, an excessive amount of ROS and RNS results in the oxidation of biological molecules such as lipids, proteins, and DNA. Oxidative stress has been reported in kidney disease, due to both antioxidant depletions as well as increased ROS production. The kidney is a highly metabolic organ, rich in oxidation reactions in mitochondria, which makes it vulnerable to damage caused by OS, and several studies have shown that OS can accelerate kidney disease progression. Also, in patients at advanced stages of chronic kidney disease (CKD), increased OS is associated with complications such as hypertension, atherosclerosis, inflammation, and anemia. In this review, we aim to describe OS and its influence on CKD progression and its complications. We also discuss the potential role of various antioxidants and pharmacological agents, which may represent potential therapeutic targets to reduce OS in both pediatric and adult CKD patients.

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368 citations

Cites background from "Kidney Disease: Improving Global Ou..."

...mentation is therefore commonly performed as part of the anemia management both in adult CKD patients [174] and in pediatric CKD patients [175, 176]....
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Journal Article•DOI•

Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management

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Maria Domenica Cappellini¹, Josep Comin-Colet², Angel L.M. de Francisco³, Axel Dignass, Wolfram Doehner⁴, Carolyn S.P. Lam⁵, Iain C. Macdougall⁶, Gerhard Rogler⁷, Clara Camaschella⁸, Rezan Kadir⁹, Nicholas J Kassebaum¹⁰, Donat R. Spahn⁷, Ali T. Taher¹¹, Khaled M. Musallam - Show less +10 more•Institutions (11)

Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico¹, Bellvitge University Hospital², University of Cantabria³, Charité⁴, National University of Singapore⁵, University of Cambridge⁶, University of Zurich⁷, Vita-Salute San Raffaele University⁸, University College Hospital⁹, Institute for Health Metrics and Evaluation¹⁰, American University of Beirut¹¹

07 Jul 2017-American Journal of Hematology

TL;DR: Practical recommendations for iron deficiency to treating physicians are provided: definition, diagnosis, and disease‐specific diagnostic algorithms to facilitate appropriate diagnosis and treatment to improve quality of life and clinical outcomes.

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Abstract: Iron deficiency, even in the absence of anemia, can be debilitating, and exacerbate any underlying chronic disease, leading to increased morbidity and mortality. Iron deficiency is frequently concomitant with chronic inflammatory disease; however, iron deficiency treatment is often overlooked, partially due to the heterogeneity among clinical practice guidelines. In the absence of consistent guidance across chronic heart failure, chronic kidney disease and inflammatory bowel disease, we provide practical recommendations for iron deficiency to treating physicians: definition, diagnosis, and disease-specific diagnostic algorithms. These recommendations should facilitate appropriate diagnosis and treatment of iron deficiency to improve quality of life and clinical outcomes.

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250 citations

Journal Article•DOI•

Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review

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Laurent Peyrin-Biroulet, Nicolas Williet, Patrice Cacoub¹•Institutions (1)

University of Paris¹

01 Dec 2015-The American Journal of Clinical Nutrition

TL;DR: It appears that for the diagnosis of ID, a cutoff of 100 μg/L for serum ferritin concentration should be considered in most conditions and 20% for TSAT, except in particular situations, including young healthy women with heavy menstrual flow.

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196 citations

Cites background from "Kidney Disease: Improving Global Ou..."

...AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACD, anemia due to chronic disease; ACP, American College of Physicians; BCG, British Columbia Guidance; BCSH, British Committee for Standards in Haematology; BSGE, British Society of Gastroenterology; CHr, content of reticulocyte hemoglobin; CKD, chronic kidney disease; CNGOF, National College of French Gynecologists and Obstetricians; CPSP, Canadian Paediatric Surveillance Program; ECCO, European Crohn’s and Colitis Organisation; ERBP, European Renal Best Practice; ESA, European Society of Anaesthesiology; ESC, European Society of Cardiology; FID, functional iron defficiency; GESA, Gastroenterological Society of Australia; HD, hemodialysis; HRC, hypochromic red cell; IBD, inflammatory bowel disease; ID, iron deficiency; ISN, International Society of Nephrology; JSDT, Japanese Society for Dialysis Therapy; KDIGO, Kidney Disease, Improving Global Outcomes; KDOQI, Kidney Disease Outcomes Quality Initiative; MCV, mean corpuscular volume; NATA, Network for Advancement of Transfusion Alternatives; NCCN, National Comprehensive Cancer Network; ND, nonhemodialysis; NICE, National Institute for Health and Care Excellence; N/A, not available; sTfR, soluble transferrin receptor; TSAT, transferrin saturation....
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...Overall, TABLE 2 (Continued ) Professional association (reference) Origin Year Context Preferential route of supplementation Target hemoglobin, g/dL Target ferritin, mg/L Target TSAT, % Others Heart disease (n = 2) ESC (33) European 2012 Acute and chronic heart failure i.v. ACP (28) American 2013 Heart disease i.v. .7 .100 Pregnancy (n = 3) BCSH (48) British 2012 ID Oral probable ID (hemodilution) Oral FMCOG (41) Mexican 2012 pregnancy Oral .10.5 300–360 — — PGSEG (36) Polish 2013 pregnancy Oral N/A N/A N/A N/A 1AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACP, American College of Physicians; ASCO, American Society of Clinical Oncology; ASH, American Society of Hematology; BCG, British Columbia Guidance; BCSH, British Committee for Standards in Haematology; BSGE, British Society of Gastroenterology; CKD, chronic kidney disease; CPSP, Canadian Paediatric Surveillance Program; ECCO, European Crohn’s and Colitis Organisation; EORTC, European Organisation for Research and Treatment of Cancer; ERBP, European Renal Best Practice; ESA, European Society of Anaesthesiology; ESC, European Society of Cardiology; ESMO, European Society for Medical Oncology; FID, functional iron defficiency; FMCOG, Mexican College of Gynecologists and Obstetricians; FNCHRU, National Foundation of Regional University Hospitals for Oncology; FNCLCC, National Foundation of Centers for the Fight against Cancer; GESA, Gastroenterological Society of Australia; HD, hemodialysis; HRBC, hypochromic binding red cell; Ht, hematocrit; IBD, inflammatory bowel disease; ID, iron deficiency; ISN, International Society of Nephrology; i.v., intravenous; JSDT, Japanese Society for Dialysis Therapy; KDIGO, Kidney Disease, Improving Global Outcomes; KDOQI, Kidney Disease Outcomes Quality Initiative; NATA, Network for Advancement of Transfusion Alternatives; NCCN, National Comprehensive Cancer Network; ND, nonhemodialysis; NICE, National Institute for Health and Care Excellence; N/A, not available; PD, peritoneal dialysis; PGSEG, Polish Gynecological Society Expert Group; QoL, quality of life; RHC, reticulocyte hemoglobin content; TSAT, transferrin saturation; UNHPC, National Unit of Oncology Clinics. a serum ferritin concentration cutoff of 100 mg/L should be considered in current practices and further clinical trials to define an ID in most conditions....
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...Ferritin concentrations should not exceed 500 mg/L (19, 32, 34, 44, 45) or 800 mg/L (19, 25, 26, 42, 43) because of the risk of exposing patients to iatrogenic complications, including infections....
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...ERBP (44) European 2009 ND-CKD ,100 ,20 —...
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...It is noteworthy that 18 guidelines reported the level of evidence, including guidelines on anesthesia (n = 1) (29), heart diseases (n = 2) (28, 33), digestive diseases (n = 3) (4, 43, 46), CKD (n = 6) (18, 21, 39, 42, 44, 45), and chemotherapy-induced anemia (n = 2) (3, 34)....
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Journal Article•DOI•

Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease

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Ashraf Mikhail¹, Chris Brown¹, Jennifer Ann Williams¹, Vinod Mathrani², Rajesh Shrivastava¹, Jonathan Evans³, Hayleigh Isaac⁴, Sunil Bhandari⁵ - Show less +4 more•Institutions (5)

Abertawe Bro Morgannwg University Health Board¹, Aneurin Bevan University Health Board², Nottingham University Hospitals NHS Trust³, Renal Association⁴, Hull and East Yorkshire Hospitals NHS Trust⁵

30 Nov 2017-BMC Nephrology

TL;DR: The current guidelines provide advice to health care professionals on how to screen chronic kidney disease patients for anaemia, which patients to investigate for other causes of anaemia and when and how to treat patients with different medications, how to ensure safe prescribing of treatment and the drugs used for its treatment.

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Abstract: Anaemia is a commonly diagnosed complication among patients suffering with chronic kidney disease. If left untreated, it may affect patient quality of life. There are several causes for anaemia in this patient population. As the kidney function deteriorates, together with medications and dietary restrictions, patients may develop iron deficiency, resulting in reduction of iron supply to the bone marrow (which is the body organ responsible for the production of different blood elements). Chronic kidney disease patients may not be able to utilise their own body’s iron stores effectively and hence, many patients, particularly those receiving haemodialysis, may require additional iron treatment, usually provided by infusion. With further weakening of kidney function, patients with chronic kidney disease may need additional treatment with a substance called erythropoietin which drives the bone marrow to produce its own blood. This substance, which is naturally produced by the kidneys, becomes relatively deficient in patients with chronic kidney disease. Any patients will eventually require treatment with erythropoietin or similar products that are given by injection. Over the last few years, several iron and erythropoietin products have been licensed for treating anaemia in chronic kidney disease patients. In addition, several publications discussed the benefits of each treatment and possible risks associated with long term treatment. The current guidelines provide advice to health care professionals on how to screen chronic kidney disease patients for anaemia, which patients to investigate for other causes of anaemia, when and how to treat patients with different medications, how to ensure safe prescribing of treatment and how to diagnose and manage complications associated with anaemia and the drugs used for its treatment.

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147 citations

Cites background from "Kidney Disease: Improving Global Ou..."

...European Renal Best Practice (ERBP) for Anaemia in CKD [5, 6] Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines for Management of anaemia in CKD [7],...
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Journal Article•DOI•

ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: Executive summary and recommendations: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina)

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Eugene Braunwald, Elliott M. Antman, John W. Beasley, Robert M. Califf, Melvin D. Cheitlin, Judith S. Hochman, Robert H. Jones, Dean J. Kereiakes, Joel Kupersmith, Thomas N. Levin, Carl J. Pepine, John W. Schaeffer, Earl E. Smith, David E Steward, Pierre Theroux, Raymond J. Gibbons, Joseph S. Alpert, David P. Faxon¹, Valentin Fuster, Gabriel Gregoratos, Loren F. Hiratzka, Alice K. Jacobs, Sidney C. Smith - Show less +19 more•Institutions (1)

University of Michigan¹

05 Sep 2000-Circulation

TL;DR: The present guidelines supersede the 1994 guidelines and summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy.

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Abstract: The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines. The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective . Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data …

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5,020 citations

Journal Article•DOI•

Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO)

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Andrew S. Levey, Kai-Uwe Eckardt, Yusuke Tsukamoto, Adeera Levin, Josef Coresh, Jerome Rossert, Dick de Zeeuw, Thomas H. Hostetter, Norbert Lameire, Garabed Eknoyan - Show less +6 more

01 Jun 2005-Kidney International

TL;DR: A survey and conference was conducted and a controversies conference was sponsored to provide a clear understanding to both the nephrology and nonnephrology communities of the evidence base for the definition and classification recommended by Kidney Disease Quality Outcome Initiative (K/DOQI).

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3,234 citations

Journal Article•DOI•

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction)...

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Jeffrey L. Anderson, Cynthia D. Adams, Elliott M. Antman, Charles R. Bridges, Robert M. Califf, Donald E. Casey, William E. Chavey, Francis M. Fesmire, Judith S. Hochman, Thomas N. Levin, A. Michael Lincoff, Eric D. Peterson, Pierre Theroux, Nanette K. Wenger, R. Scott Wright, Sidney C. Smith, Alice K. Jacobs, Jonathan L. Halperin, Sharon A. Hunt, Harlan M. Krumholz, Frederick G. Kushner, Bruce W. Lytle, Rick A. Nishimura, Joseph P. Ornato, Richard L. Page, Barbara Riegel - Show less +22 more

14 Aug 2007-Circulation

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Abstract: Angina/Non-ST-Elevation Myocardial Infarction : ACC/AHA 2007 Guidelines for the Management of Patients With Unstable ISSN: 1524-4539 Copyright © 2007 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX doi: 10.1161/CIRCULATIONAHA.107.18194

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2,605 citations

Journal Article•DOI•

Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease

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Ajay K. Singh¹, Lynda A. Szczech, Kezhen L. Tang, Huiman X. Barnhart, Shelly Sapp, Marsha Wolfson, Donal N. Reddan, Abstr Act - Show less +4 more•Institutions (1)

Partners HealthCare¹

16 Nov 2006-The New England Journal of Medicine

TL;DR: The use of a target hemoglobin level of 13.5 g per deciliter (as compared with 11.3 g perDeciliter) was associated with increased risk and no incremental improvement in the quality of life and the use of epoetin alfa targeted to achieve a level of 11.4 g perdeciliter was not associated with an increased risk.

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Abstract: Background Anemia, a common complication of chronic kidney disease, usually develops as a consequence of erythropoietin deficiency. Recombinant human erythropoietin (epoetin alfa) is indicated for the correction of anemia associated with this condition. However, the optimal level of hemoglobin correction is not defined. Methods In this open-label trial, we studied 1432 patients with chronic kidney disease, 715 of whom were randomly assigned to receive a dose of epoetin alfa targeted to achieve a hemoglobin level of 13.5 g per deciliter and 717 of whom were assigned to receive a dose targeted to achieve a level of 11.3 g per deciliter. The median study duration was 16 months. The primary end point was a composite of death, myocardial infarction, hospitalization for congestive heart failure (without renal replacement therapy), and stroke. Results A total of 222 composite events occurred: 125 events in the high-hemoglobin group, as compared with 97 events in the low-hemoglobin group (hazard ratio, 1.34; 95% confidence interval, 1.03 to 1.74; P = 0.03). There were 65 deaths (29.3%), 101 hospitalizations for congestive heart failure (45.5%), 25 myocardial infarctions (11.3%), and 23 strokes (10.4%). Seven patients (3.2%) were hospitalized for congestive heart failure and myocardial infarction combined, and one patient (0.5%) died after having a stroke. Improvements in the quality of life were similar in the two groups. More patients in the high-hemoglobin group had at least one serious adverse event. Conclusions The use of a target hemoglobin level of 13.5 g per deciliter (as compared with 11.3 g per deciliter) was associated with increased risk and no incremental improvement in the quality of life. (ClinicalTrials.gov number, NCT00211120.)

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2,474 citations

Journal Article•DOI•

Normalization of Hemoglobin Level in Patients with Chronic Kidney Disease and Anemia

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Tilman B. Drüeke¹, Francesco Locatelli, Naomi Clyne, Kai-Uwe Eckardt, Iain C. Macdougall, Dimitrios Tsakiris, Hans-Ulrich Burger, Armin Scherhag - Show less +4 more•Institutions (1)

French Institute of Health and Medical Research¹

16 Nov 2006-The New England Journal of Medicine

TL;DR: In patients with chronic kidney disease, early complete correction of anemia does not reduce the risk of cardiovascular events and there was no significant difference in the combined incidence of adverse events between the two groups.

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Abstract: BACKGROUND Whether correction of anemia in patients with stage 3 or 4 chronic kidney disease improves cardiovascular outcomes is not established. METHODS We randomly assigned 603 patients with an estimated glomerular filtration rate (GFR) of 15.0 to 35.0 ml per minute per 1.73 m 2 of body-surface area and mild-to-moderate anemia (hemoglobin level, 11.0 to 12.5 g per deciliter) to a target hemoglobin value in the normal range (13.0 to 15.0 g per deciliter, group 1) or the subnormal range (10.5 to 11.5 g per deciliter, group 2). Subcutaneous erythropoietin (epoetin beta) was initiated at randomization (group 1) or only after the hemoglobin level fell below 10.5 g per deciliter (group 2). The primary end point was a composite of eight cardiovascular events; secondary end points included left ventricular mass index, quality-of-life scores, and the progression of chronic kidney disease. RESULTS During the 3-year study, complete correction of anemia did not affect the likelihood of a first cardiovascular event (58 events in group 1 vs. 47 events in group 2; hazard ratio, 0.78; 95% confidence interval, 0.53 to 1.14; P = 0.20). Left ventricular mass index remained stable in both groups. The mean estimated GFR was 24.9 ml per minute in group 1 and 24.2 ml per minute in group 2 at baseline and decreased by 3.6 and 3.1 ml per minute per year, respectively (P = 0.40). Dialysis was required in more patients in group 1 than in group 2 (127 vs. 111, P = 0.03). General health and physical function improved significantly (P = 0.003 and P<0.001, respectively, in group 1, as compared with group 2). There was no significant difference in the combined incidence of adverse events between the two groups, but hypertensive episodes and headaches were more prevalent in group 1. CONCLUSIONS In patients with chronic kidney disease, early complete correction of anemia does not reduce the risk of cardiovascular events. (ClinicalTrials.gov number, NCT00321919.)

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1,955 citations

"Kidney Disease: Improving Global Ou..." refers background or methods in this paper

...(chest pain, orthostatic hypotension, tachycardia unresponsive to fluid resuscitation or congestive heart failure) [56]....
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...In 2007 following the publication of the Cardiovascular Reduction Early Anaemia Treatment Epoetin beta (CREATE) [56] and Correction of Haemoglobin and Outcomes in Renal Insufficiency (CHOIR) [57] studies, KDOQI guidelines set a lower Hb limit (11....
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...In particular, they suggest considering transfusion at Hb values ≤7 g/dL or at Hb values ≤8 g/dL in postoperative surgical patients [56]....
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...In 2007 following the publication of the Cardiovascular Reduction Early Anaemia Treatment Epoetin beta (CREATE) [56] and Correction of Haemoglobin and Outcomes in Renal Insufficiency (CHOIR) [57] studies, KDOQI guidelines set a lower Hb limit (11.0 g/dL) and suggested an upper limit around 12 g/dL without intentionally exceeding 13 g/dL....
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...According to the panel, a liberal transfusion strategy is unlikely to result in clinically important reduction in mortality or on other secondary endpoints but exposes patients to a much higher number of blood transfusions [56]....
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