Anemia management in chronic kidney disease: what have we learned after 17 years?

Anemia management remains controversial in patients with chronic kidney disease (CKD). The overwhelming conclusion from retrospective data analyses show a strong correlation between higher hemoglobin values and improved outcomes, including mortality, hospitalization, left ventricular hypertrophy, and quality of life. However, the evidence available from two large prospective trials in CKD comparing hemoglobin values near the current target of 11-12 g/dl with normalization or near normalization were stopped, as there was a trend toward worsening outcomes in the higher hemoglobin groups. This disparity suggests that patients who have or achieve high hemoglobin values on low doses or no erythropoietin may be inherently different from the general CKD population. Therefore targeting to a hemoglobin value above the current recommendation with intermittent erythropoietin seems unwarranted until randomized prospective trials demonstrate both safety and efficacy.