Humpty Dumpty sat on a
wall,
Humpty Dumpty had a great
fall.
All the King's horses, And
all the King's men
Couldn't put Humpty
together again!
Why use this nursery rhyme
in the context of anemia in dialysis patients? Has Singh finally gone mad? No,
not yet. Many senior dialysis docs came up to me at the ASN and told
me how confusing the FDA label is. Some comments: “There is no lower
level of hemoglobin”. “There is no target range”. “We don’t know whether to
hold or reduce the epo dose as the hemoglobin (Hb) level approaches 11 g/dL”.
Epo treatment became so
big that we need time to build it up again with some cohesion and logic.
Back to Humpty
Dumpty. The latest information on Humpty Dumpty is that it was a huge cannon that sat on a wall of a castle in
the town of Colchester, England around 1648. A shot from a Parliamentary cannon
succeeded in damaging the wall beneath Humpty Dumpty, which caused the cannon
to tumble to the ground. The Royalists, or Cavaliers, 'all the King's men'
attempted to raise Humpty Dumpty on to another part of the wall, but because
the cannon was so heavy ' All the King's horses and all the King's men couldn't
put Humpty together again.'
It seems that most
nephrologists are aiming for a Hb target of 9 to 11 g/dL. What might happen by aiming for a lower target?
I ran into David Goldfarb
yesterday on my way to a session at the ASN. David is a senior nephrologist at NYU. He told me
that he examined this issue in a paper that he published this month in Nephron Extra – it’s available open access.
Nguyen and colleagues hypothesized that
reducing the target Hb would prevent levels >12 g/dl and lead to significant
cost savings. Their target Hb
range was reduced to 9–11 g/dl from 10–12 g/dl. 35 chronic hemodialysis
patients received epo and intravenous iron from January to December 2009. EPO
was administered via subcutaneous injection weekly or twice weekly. The mean
monthly Hb level changed from 11.2 to 10.6 g/dl. The percentages of patients
with mean Hb >10.0, 12.0 and 13.0 g/dl were 82 ± 6.5, 10 ± 5.6 and 1.8 ±
1.9%, respectively. Weekly EPO dose decreased from 9,500 to 5,600 units, a 40%
reduction per dose per patient and costs. The savings exceeded USD 60,000 per
year for 35 patients. More than 80% of patients had transferrin saturation
>20% and ferritin >200 ng/ml throughout the entire period.
Nguyen and Goldfarb
concluded: “Lowering the target Hb range to 9–11 g/dl in HD patients treated
with EPO achieved quality anemia management with significantly fewer numbers of
patients with a dangerous Hb rise >12 g/dl and at the same time resulted in
cost savings”.
KDIGO will probably
recommend a Hb target range of 9 to 11.5 g/dL. I don’t agree with 11.5 g/dL at
the top end of the range. If one is using a target range for anemia management
in a dialysis patient you should be guided by the Normal Hematorcrit study in which the lower Hb arm was 9 to 11 g/dL. Patients randomized to
this target range had better outcomes than those patient’s randomized to 13 to
15 g/dL.
I suggest that individualization
is important; one should establish the Hb trigger for the patient. For most, it
will be a Hb of 9 g/dL, but for others it might be a bit higher (or even a
little lower). The Hb trigger is the level of Hb at which you feel you have to
intervene with either starting epo (or an increase in epo dose), iron, or a
blood transfusion.
According to legend, Humpty
Dumpty could not be put back together again. With treating anemia, we have to. And, it will result in lower cost and it will probably be safer.
