An expert opinion on the current treatment of anemia in patients with kidney disease.

INTRODUCTION: Anemia, a frequent and early complication of chronic kidney disease (CKD), not only impairs quality of life but is also an independent risk factor for adverse cardiovascular outcomes. Erythropoiesis-stimulating agents (ESAs), together with iron, are the main therapeutic tool to correct anemia in CKD patients nowadays. AREAS COVERED: Following a literature search on PubMed using 'anemia', 'hemoglobin', 'erythropoietin' and 'target' as keywords, we critically analyzed ESAs, looking in depth at their distinct characteristics and possible advantages in the clinical setting. The introduction of biosimilars into the European market is also discussed. Finally, we reviewed current evidence about the optimal hemoglobin (Hb) target to aim at in CKD patients receiving ESA and possible treatment indications by international guidelines or health institutions. EXPERT OPINION: All ESAs are effective agents to correct anemia. Newer molecules have been developed with an improved pharmacokinetic and pharmacodynamic profile. This translates into longer administration intervals than can be a true advantage, mainly for CKD patients not receiving dialysis. Short-acting epoetins, including biosimilars, should be administered more often, but can be cheaper than last-generation molecules. Following publication of the TREAT study, there is considerable confusion about the optimal Hb target to aim for in CKD patients using ESA. While waiting for Kidney Disease Global Outcome (KDIGO) guidelines recommendations, we believe that the general approach to anemia management in CKD patients should still aim at Hb levels of 11 - 12 g/dl; however, it is wise to use caution in those patients who are hyporesponsive to ESA or have a previous history of stroke or malignancies.