NKF-KDOQI Clinical Practice Guidelines and Clinical Practice

							NKF-KDOQI Clinical Practice
Guidelines and Clinical Practice
Recommendations for Anemia in
Chronic Kidney Disease

UPDATE OF HEMOGLOBIN TARGET
Am.J.Kidney.Dis. 50 (3):471-530, 2007.
KDOQI Anemia
Organization
   Evidence Review Team
           Tufts New England Medical Center
   Work Group
          9 Adult Nephrologists
          2 Pediatric Nephrologists
          2 Hematologists
          1 Nurse Practitioner
          1 Dietician
CPR and CPG 2.1: Hb Target
Introduction
    The Hb target is the
     intended aim of ESA
     therapy for the individual
     CKD patient. In clinical
     practice, achieved Hb
     results vary considerably
     from the Hb target.
CPR 2.1.1
Considerations
    In the opinion of the work group, selection
     of the Hb target and selection of the Hb
     level at which ESA therapy is initiated in
     the individual patient should include
     consideration of potential benefits
     (including improvement in quality of life
     and avoidance of transfusion) and potential
     harms (including the risk of life-
     threatening adverse events). (Clinical
     Practice RECOMMENDATION)
CPR 2.1.2
Selection of the Hb target
    In the opinion of the work group,
     in dialysis and non-dialysis CKD
     patients receiving ESA therapy, the
     selected Hb target should generally
     be in the range of 11.0 to 12.0
     g/dL. (Clinical Practice
     RECOMMENDATION)
CPG 2.1.3
Hb targets to avoid
    In dialysis and non-dialysis
     CKD patients receiving ESA
     therapy, the Hb target should
     not be above 13.0 g/dL.
     (Clinical Practice
     GUIDELINE -
     MODERATELY STRONG
     EVIDENCE)
Rationale: 2.1.2
Rationale: 2.1.2
  Distinguishing Target Hb from
  Achieved Hb
        Target Hb is the aim of ESA therapy
        Achieved Hb is the result of ESA
         therapy
        Achieved Hb results vary considerably
         from the Hb target
        Safety of achieved Hb relative to 11-12
         g/dL target Hb or Hb > 11 g/dL
         threshold is well-established
Rationale: 2.1.3
  The Hb target should not be above 13.0 g/dL
  (Moderately Strong Recommendation)
        Evidence from RCTs
           Considered all trials that compared Hb
            target > 13.0 g/dL to lower target
           All these RCTs tested the hypothesis that
            the higher target would prevent adverse
            cardiovascular events or mortality, or all
            cause mortality
           None showed a benefit on those outcomes
Meta-Analysis
   Performed by Evidence Review Team
   RCTs with ≥ 6 months follow-up, no
    restriction on study size
   Statistical model: random effects
   Separated dialysis from non-dialysis CKD
    trials
   Combined all cardiovascular disease events for
    analysis of cardiovascular adverse event risk
Rationale: 2.1.3
  Relative mortality risk for assignment to
  higher treatment targets: Non-Dialysis-CKD
                                        Higher
                                       Hb Target
                                            11.7
                                       11.0-11.7
                                            13.0
                                       12.0-14.0
                                       13.0-15.0
                                       13.0-15.0
                                            13.5
                                            11.0




          Relative Risk: 1.02, 95% CI 0.63-1.61
 Rationale: 2.1.3
Relative risk of cardiovascular events for
assignment to higher targets: Non-dialysis CKD
                                          Higher
                                         Hb Target

                                              11.7
                                         12.0-14.0
                                         13.0-15.0
                                         13.0-15.0
                                              13.5
                                         13.0-15.0




           Relative Risk: 1.24, 95% CI 1.02-1.51
Rationale: 2.1.3
  Relative mortality risk for assignment to
  higher treatment targets: Dialysis CKD
                                       Higher
                                      Hb Target

                                           14.0
                                      13.0-14.0
                                      13.5-16.0
                                      13.5-14.5




          Relative Risk: 1.12, 95% CI 0.91-1.37
Rationale: 2.1.3
  Relative risk of cardiovascular events for
  assignment to higher targets: Dialysis CKD

                                       Higher
                                      Hb Target

                                          14.0
                                      13.0-14.0
                                      13.5-14.5




          Relative Risk: 1.14, 95% CI 0.79-1.64
Rationale: 2.1.3
  The Statement:
  Hb Target should not be above 13 g/dL
        Reflects Work Group judgment
          The possibility to cause harm weighs more
           heavily than the potential to improve
           quality of life and reduce the likelihood of
           transfusions
        Moderately strong, evidence-based, clinical
         practice guideline