Maintaining control over haemoglobin levels: optimizing the management of anaemia in chronic kidney disease

The introduction of erythropoiesis-stimulating agents radically advanced the management of anaemia associated with chronic kidney disease (CKD). The European Best Practice Guidelines recommend that most patients with CKD achieve a target haemoglobin (Hb) >/=11 g/dl to reduce the risk of adverse outcomes. The optimal upper Hb level has not been determined and will likely vary among CKD patient populations. Recently reported studies show evidence that normalising Hb ( approximately 14 g/dl) in CKD may increase the risk of adverse events and puts attention to the importance of the upper Hb target. Most patients can achieve target Hb levels with proper treatment. However, recent studies have demonstrated that while average Hb levels may fall within desired targets, the Hb levels of many patients are not being adequately controlled, i.e. their Hb levels are not consistently maintained within a specified target range over time. Furthermore, data indicate that failing to control Hb levels over time may increase the risk of adverse outcomes, including mortality. This review will discuss the challenges in controlling Hb in the CKD patient population, particularly in haemodialysis patients. Factors that affect Hb control over time will be considered, as well as the clinical criteria for its assessment. Although challenging, control of Hb is manageable and has potential clinical benefits.