Therapy of anemia: is it only a number to reach or are there other variables to control?

Following the publication of the TREAT study, the treatment of anemia in patients with chronic kidney disease (CKD) has become much more complicated than before. The nephrologist needs to analyze the individual patient and prescribe the best treatment option for that patient. Treatment individualization has thus become the mainstay of anemia management. This paradigm needs to take into account the hemoglobin (Hb) level at the start and during erythropoiesis-stimulating agent (ESA) therapy, ESA dose, patient comorbidities and concomitant iron therapy. All these factors are strictly interrelated. Caution is suggested when using ESA at high dose, especially in patients with comorbidities and/or in those who are hyporesponsive to treatment. According to KDIGO guidelines, Hb levels should not exceed the value of 11.5 g/dl during ESA therapy. Recently, iron therapy has received growing attention in an effort to use the lowest possible dose of ESA. However, the long-term risk in maintaining CKD patients with very high ferritin values is still unknown.