Higher target haemoglobin level and early anaemia treatment: different or complementary concepts?

There is little doubt that epoetin is a highly effective treatment for rena l anaemia. However, it has been used primarily to treat dialysis patients, in whom there is good evidence that it induces significant improvements in cardiac function, exercise capacity, and quality of life. Unfortunately, no ne of these three major parameters is completely normalized. There are thre e possible reasons for this: (i) the anaemia is not fully corrected, (ii) t oo much damage has already occurred by the time the patient starts dialysis , and (iii) other contributory factors may be playing a part. Although the effects of completely correcting renal anaemia have been examined in variou s studies, the results have not been as positive as expected. It therefore seems appropriate to consider a new strategy in which epoetin therapy is in itiated at an earlier stage in the course of the disease, e.g. at a haemogl obin concentration of 11 g/dl or less. It is possible, for example, that ea rlier treatment of anaemia could prevent many cardiac problems and other mo rbidities in renal patients. In addition, if epoetin therapy is started in patients who have not been exposed to long-term chronic anaemia, fewer comp lications may he encountered when reversing the anaemia. Higher target haem oglobin concentrations may also be appropriate in these patients. It would certainly be inappropriate, however, to extrapolate the data on normalizati on of haemoglobin in dialysis patients to the pre-dialysis population. It i s therefore necessary to re-examine the issue of optimal target haemoglobin concentration in pre-dialysis patients. One of the challenges in the new m illennium must be to better understand the consequences of initiating treat ment of anaemia earlier in the course of chronic renal failure.