How should anaemia be managed in pre-dialysis patients?

Anaemia is a common problem in patients with renal failure, whether or not they are on dialysis. There is a continuum of declining renal function. In addition, the creatinine clearance at which dialysis is initiated varies widely between institutions and between studies. The term 'progressive renal insufficiency' is therefore preferable to 'pre-dialysis'. The adverse effects of renal anaemia on left ventricular mass become apparent early in the course of progressive renal insufficiency; 75% of patients starting dialysis already have left ventricular hypertrophy (LVH). Correction of anaemia in patients with progressive renal insufficiency has been shown to improve physical function and anaemia-related symptoms, but no controlled studies have yet been conducted to determine its effects on LVH. Although one animal study generated some concern that epoetin may exacerbate a decline in renal function, there is no evidence from human studies for any such effect. Treatment of anaemia with epoetin in anaemic patients with progressive renal insufficiency is therefore recommended, provided blood pressure is controlled. To date, however, there are insufficient data to determine whether normalization of haemoglobin is advisable in this patient group. Detection and correction of iron deficiency is important to achieve the full benefits of epoetin, though recommendations cannot yet be made regarding the optimum route and timing of iron supplementation in patients with progressive renal insufficiency. In these patients the role of other adjuvant therapies, such as L-carnitine, vitamin B6, vitamin B12 and folic acid, also requires further investigation.