title: Critical appraisal of randomized controlled trials of anemia correction in patients with renal failure.
abstract: OBJECTIVE
  Recent randomized controlled trials (RCTs) have reported risks and benefits in the correction of anemia using erythropoietin-stimulating agents (ESAs) in patients with predialysis chronic kidney disease (CKD) or end-stage renal disease. The purpose of this review is to critically appraise the RCTs most relevant to clinical decision-making.
  
  
  RESULTS
  The Trial to Reduce cardiovascular Events with Aransep Therapy (TREAT) is the biggest and best designed RCT performed so far, enrolling 4038 diabetic patients with CKD in a double-blind, placebo-controlled trial. Comparing the high hemoglobin (Hb) darbopoietin group with placebo, it reported no difference in cardiac and renal outcomes, a significantly increased risk of stroke, and modest improvement in fatigue and transfusion rate. Meta-analysis demonstrated that correction of anemia with ESA was associated with a significantly increased risk of hypertension and vascular access clotting and an increased risk of death that approached statistical significance. Quality-of-life improvements appeared to maximize in the target Hb range of 10-12 g/dl.
  
  
  CONCLUSIONS
  Treatment of renal anemia using ESAs to target Hb higher than 13 g/dl is harmful. Treatment of Hb below 9 g/dl provides substantial transfusion and quality-of-life benefits, but safety is unknown. Target Hb levels of 10-12 g/dl seem reasonable, but increasing ESA doses in hyporesponsive patients to achieve a specific target is not.
authors.affiliation: Division of Nephrology, Health Sciences Centre, Memorial University, St John's, Newfoundland and Labrador, Canada. pparfrey@mun.ca
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Parfrey
mesh_terms: D000740:Anemia / Q000097:blood / Q000188:drug therapy*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D015201:Meta-Analysis as Topic; D016032:Randomized Controlled Trials as Topic; D051437:Renal Insufficiency / Q000150:complications*
chemical_list: D006454:Hemoglobins