Should Dose of EPO in CKD Be Individualized For Patient’s Quality of Life? Interview with:
Dr. Navdeep Tangri
Attending physician and Assistant Professor in the Division of Nephrology
Department of Medicine and the Department of Community Health Sciences
University of Manitoba

and Dr. David Collister
Seven Oaks General Hospital Renal Program
Winnipeg, Manitoba Canada.

Medical Research: What is the background for this study? What are the main findings?

Response: Anemia is common in chronic kidney disease (CKD) including dialysis and its treatment with erythopoetin stimulating agents (ESAs) reduces the need for blood transfusions and has varying effects on morbidity and mortality. The optimal hemoglobin (HGB) targets for treating anemia in CKD are controversial with safety concerns around the normalization of hemoglobin levels due to an increase in cardiovascular (CV) events. The effects of ESAs on health related quality of life (HRQOL) are unclear with individualization o fhemoglobin targets being controversial as clinicians and patients attempt to balance perceived HRQOL benefits with cardiovascular risk.

We performed an updated meta-analysis of randomized controlled trials (RCTs) that evaluated the treatment of anemia in CKD with ESAs that targeted higher versus lower hemoglobin targets using validated HRQOL metrics including SF-36 and KDQ. We included 17 studies and found that higher hemoglobin targets compared to lower HGB targets did result in a statistically significant difference in HRQOL and thus did not improve HRQOL beyond a clinically meaningful threshold. Any change in HRQOL was further attenuated in dialysis subgroups.

Medical Research: What should clinicians and patients take away from your report?

Response: Our results do not support individualizing hemoglobin targets in CKD patients with anemia treated with ESAs for the purpose of improving HRQOL. While certain domains of HRQOL may be more responsive to higher HGB targets in CKD, any change did not achieve the minimal clinically important difference to justify the CV risks associated with higher HGB targets in the populations studied.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: Given the lack of ongoing large RCT of ESAs in CKD, this study provides a contemporary and likely definitive summary of this research area. However, patient-reported outcomes including health related quality of life domains need to be considered and accurately reported in any future studies of ESAs or novel agents for the treatment of anemia in CKD.

Collister D, Komenda P, Hiebert B, Gunasekara R, Xu Y, Eng F, et al. The Effect of Erythropoietin-Stimulating Agents on Health-Related Quality of Life in Anemia of Chronic Kidney Disease: A Systematic Review and Meta-analysis. Ann Intern Med. doi:10.7326/M15-1839


Navdeep Tangri and and Dr. David Collister (2016). Should Dose of Erythopoetin Stimulating Agents CKD Be Individualized For Patient’s Quality of Life