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Hemoglobin Variability in Anemia of Chronic Kidney Disease

Kamyar Kalantar-Zadeh^* and George R. Aronoff

^* Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, and UCLA David Geffen School of Medicine, Torrance and Los Angeles, California; and Kidney Disease Program, University of Louisville School of Medicine, Louisville, Kentucky

Reprint requests: Dr. Kamyar Kalantar-Zadeh, Harbor-UCLA Medical Center, 1124 W Carson St., Torrance, CA 90502. Phone: 310-222-3891; Fax: 310-782-1837; E-mail: kamkal{at}ucla.edu

Correspondence: Dr. George R. Aronoff, Kidney Disease Program, 615 South Preston Street, Louisville, KY 40202. Phone: 502-852-5757; Fax: 502-852-0039; E-mail: gra{at}louisville.edu

Hemoglobin levels in individuals with chronic kidney disease fluctuate frequently above or below the recommended target levels within short periods of time even though the calculated mean hemoglobin remains within the target range of 11 to 12 g/dl. Both pharmacologic features and dosing of erythropoiesis-stimulating agents may lead to cyclic pattern of hemoglobin levels within the recommended range. Several longitudinal studies highlight the complexity of maintaining stable hemoglobin levels over time. As a consequence, patients may risk increased hospitalization and mortality, because both low and high hemoglobin levels are associated with increased cardiovascular events and death. The duration of time that hemoglobin remains higher or lower than the target thresholds may be important to adverse outcomes. It is not clear whether adverse effects of hemoglobin variability are because of the therapy with erythropoiesis-stimulating agents and/or iron or despite such a therapy. Several factors affect hemoglobin variability, including those that are drug related, such as pharmacokinetic parameters, patient-related differences in demographic characteristics, and factors affecting clinical status, as well as clinical practice guidelines, treatment protocols, and reimbursement policies. Strategies that consider each of these factors and reduce hemoglobin variability may be associated with improved clinical outcomes.

Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673