1. From this systematic review and meta-analysis, use of erythropoietin-stimulating agents (ESAs) to achieve high hemoglobin targets in patients with chronic kidney disease (CKD) did not significantly improve health-related quality of life (HRQOL) compared to using ESAs to achieve lower hemoglobin targets.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Erythropoietin-stimulating agents (ESAs), a class of drugs that boost hemoglobin levels, are frequently used to combat anemia in patients with chronic kidney disease (CKD). Despite the potentially severe side effects of using ESAs, physicians often prescribe them to help patients achieve “high” hemoglobin targets, with the notion that higher hemoglobin levels may improve quality of life. Therefore, this study aimed to test whether achieving higher hemoglobin levels would improve health-related quality of life (HRQOL). The study combined results from prior trials of ESAs used to treat anemia in patients with CKD and compared improvement in HRQOL among trial participants who were randomized to either higher or lower hemoglobin targets. Overall, trial participants who were randomized to higher targets showed no clinically significant improvements in HRQOL compared to trial participants randomized to lower targets. This result was also consistent among key subgroups, such as participants on dialysis. Importantly, the trials included in this study varied in terms of what hemoglobin targets were considered “high” and “low”, as well as in which ESAs were used and the duration of follow-up, potentially limiting these findings. Nevertheless, these results suggest that using higher hemoglobin targets to guide ESA therapy among patients with CKD likely results in no clinically significant benefit to HRQOL.
In-Depth [systematic review and meta-analysis]: This study combined results from 17 randomized, controlled trials of ESAs to treat anemia in participants with CKD. All trials used two hemoglobin targets, a “low” (or placebo) target, which ranged from 7.4–12 g/L, and a “high” target, which ranged from 10.2–13.6 g/L. Included trials used two measures of HRQOL, the Short-Form Health Survey (SF-36), and the Kidney Dialysis Questionnaire (KDQ), and measured HRQOL at least twice during the trial. Overall, there was no clinically significant improvement in HRQOL in participants randomized to high hemoglobin targets compared to participants randomized to low targets. In subgroup analysis, physical function improved among non-dialysis CKD participants randomized to achieve higher hemoglobin targets (SF-36 difference 3.61, 95%CI 6.54 to 0.67), but this improvement was not clinically meaningful.
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