Higher target haemoglobin level and early anaemia treatment: different or complementary concepts?

There is little doubt that epoetin is a highly effective treatment for renal anaemia. However, it has been used primarily to treat dialysis patients, in whom there is good evidence that it induces significant improvements in cardiac function, exercise capacity, and quality of life. Unfortunately, none of these three major parameters is completely normalized. There are three possible reasons for this: (i) the anaemia is not fully corrected, (ii) too much damage has already occurred by the time the patient starts dialysis, and (iii) other contributory factors may be playing a part. Although the effects of completely correcting renal anaemia have been examined in various studies, the results have not been as positive as expected. It therefore seems appropriate to consider a new strategy in which epoetin therapy is initiated at an earlier stage in the course of the disease, e.g. at a haemoglobin concentration of 11 g/dl or less. It is possible, for example, that earlier treatment of anaemia could prevent many cardiac problems and other morbidities in renal patients. In addition, if epoetin therapy is started in patients who have not been exposed to long-term chronic anaemia, fewer complications may be encountered when reversing the anaemia. Higher target haemoglobin concentrations may also be appropriate in these patients. It would certainly be inappropriate, however, to extrapolate the data on normalization of haemoglobin in dialysis patients to the pre-dialysis population. It is therefore necessary to re-examine the issue of optimal target haemoglobin concentration in pre-dialysis patients. One of the challenges in the new millennium must be to better understand the consequences of initiating treatment of anaemia earlier in the course of chronic renal failure.