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Updated: Jan 20, 2026
Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
The Evolution of Target Hemoglobin Levels in Anemia of Chronic Kidney Disease
Jonathan Bazeley1, Jay B Wish1
1Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN.
Insights
Evolving guidelines for erythropoiesis-stimulating agents (ESAs) in chronic kidney disease (CKD) anemia management have expanded patient eligibility and targeted hemoglobin levels over 3 decades, informed by morbidity, mortality, and quality of life data.
Area of Science:
- Nephrology
- Hematology
- Pharmacology
Background:
- Erythropoiesis-stimulating agents (ESAs) have been used since 1989 to manage anemia in chronic kidney disease (CKD).
- Initial ESA treatment focused on severely anemic patients, later expanding to include most dialysis and many non-dialysis CKD patients.
- Determining optimal hemoglobin targets for ESA therapy has been a focus for nephrology societies and regulatory agencies.
Purpose of the Study:
- To review the literature influencing the evolution of ESA treatment strategies for CKD anemia over the past 30 years.
- To analyze how evidence on morbidity, mortality, and quality of life has shaped ESA guidelines.
- To provide insights into applying this historical knowledge to current patient care.
Main Methods:
- Literature review of studies published over the last three decades.
- Analysis of evolving clinical practice guidelines from major nephrology societies and regulatory bodies.
- Synthesis of evidence regarding the impact of ESAs on various clinical endpoints.
Main Results:
- ESA therapy for CKD anemia has broadened significantly since its introduction.
- Guidelines for target hemoglobin levels have been revised multiple times based on accumulating evidence.
- Understanding the impact of ESAs on patient outcomes has been crucial for guideline development.
Conclusions:
- The management of anemia in CKD with ESAs has evolved considerably, reflecting a dynamic interplay between clinical evidence and therapeutic strategies.
- Current ESA application in CKD is informed by a comprehensive understanding of its effects on patient morbidity, mortality, and quality of life.
- Ongoing evaluation of scientific literature remains essential for optimizing ESA therapy in CKD patients.
Abstract:
Since the introduction of erythropoiesis-stimulating agents (ESAs) into clinical practice in 1989, considerable effort has been put forth toward identifying the optimal treatment strategy for managing anemia of CKD. After initial treatment of only the most severely anemic patients, therapy was subsequently expanded to include most patients on dialysis and many nondialysis CKD patients. Many nephrology societies and regulatory agencies have sought to identify the most appropriate hemoglobin levels to which ESA therapy should be targeted. As increasing evidence became available about the impacts of ESAs on varying endpoints including morbidity, mortality, and quality of life, the guidelines put forth by such agencies evolved over time. We review the literature impacting these determinations through the past 3 decades and comment on how this informs the application of this knowledge to the care of patients today.
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