Erythropoietic stimulating agents and quality of a patient's life: individualizing anemia treatment.

Erythropoietic stimulating agents (ESAs) such as erythropoietin have been used for decades to treat the anemia of CKD. Clinical practice guidelines suggest target hemoglobin levels >10 g/dl, and average Hb levels have risen from 9.6 to 12.0 g/dl. Several studies have shown trends for higher mortality and myocardial infarction, higher BP, increased vascular access thrombosis, and strokes in patients treated to target Hb ≥13 g/dl. Patients with profound anemia suffer from symptoms of fatigue, poor energy, weakness, and shortness of breath. Such symptoms reported directly by patients, or patient-reported outcomes (PROs), may be a valuable tool to target ESA treatment in anemic CKD patients. Studies show that improvements in anemia correlate with improvements in these PRO domains in some individuals. We propose that instead of Hb targets for all patients, treatment of anemia should be directed toward improving the areas of patient-perceived quality of life most affected by anemia. PROs can be used by individual patients to prioritize the risks and benefits of ESA treatment. Patients, along with their physicians, can examine Hb level in the context of patients' perception of their quality of life and use ESAs judiciously to improve these perceptions.