Erythropoiesis-stimulating agent treatment with full anemia correction: a new perspective

Erythropoiesis stimulating agent (ESA) treatment has been a major advance in the care of patients with kidney disease, resulting in reduced symptoms and blood transfusions, and improved quality of life. Recent studies, however, have indicated that attempts to treat to near normal Hgb targets may result in increased risk for death or cardiovascular events. This had led to an appropriate increase in caution, and avoidance of Hgb targets greater than 13 g/dl. There is, however, a great lack of understanding of the mechanisms of harm with more intensive ESA treatment. One avenue for investigation in medicine is analysis of outlier experience. In this article we will consider the experience of a group of dialysis units in Berlin, Germany, that have achieved outstanding patient outcomes despite targeting normal Hgb levels with ESA treatment. The purpose is to explore ancillary treatment processes that could mitigate any harmful effects of ESA therapy. We do not seek to propose that treatment with ESAs to higher Hgb targets is safe, but rather to use this outlier experience to gain knowledge and to generate hypotheses to be tested in future studies.