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• W2015355989 abstract "Quality of life for patient groups. Along with survival and other types of clinical outcome, patients' quality of life is an important indicator of the effectiveness of the medical care that they receive. Quality of life in patients with end-stage renal disease (ESRD) is influenced by the disease itself and by the type of renal replacement therapy. Numerous studies have enabled the identification of the effects of factors such as anemia, age, comorbidity, depression, etc. on quality of life. It is possible to counteract many of these effects, and the earlier this is done, the more effective the results will be. Among replacement therapies, transplantation appears to be the one that gives the best quality of life results for very large groups of patients. In the case of elderly patients or patients with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all the possible factors into account. Quality of life for patient groups. Along with survival and other types of clinical outcome, patients' quality of life is an important indicator of the effectiveness of the medical care that they receive. Quality of life in patients with end-stage renal disease (ESRD) is influenced by the disease itself and by the type of renal replacement therapy. Numerous studies have enabled the identification of the effects of factors such as anemia, age, comorbidity, depression, etc. on quality of life. It is possible to counteract many of these effects, and the earlier this is done, the more effective the results will be. Among replacement therapies, transplantation appears to be the one that gives the best quality of life results for very large groups of patients. In the case of elderly patients or patients with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all the possible factors into account. End-stage renal disease (ESRD) has a considerable impact on the functional status and quality of life (QoL) perceived by the patient. Even in relatively early stages, it is accompanied by symptoms that affect daily life; renal replacement therapies such as hemodialysis or peritoneal dialysis only partially correct the uremia and also render necessary substantial lifestyle changes. A functioning transplant restores kidney function but it also brings with it new pathology associated with immunosuppression. The characteristics of dialysis patients have changed in the last 10 years and a growing number of elderly patients with a considerable degree of comorbidity are receiving renal replacement therapies. The number of patients returning to dialysis after a transplant failure is also increasing. In many cases, patients receive different types of therapy in the course of their lives. All of these situations have varying effects on the quality of life. It is broadly accepted that, in addition to the classic parameters such as urea kinetics, albumin, etc., the definition of adequate dialysis should also include the quality of life experienced by the patient and it is the health teams' responsibility to enable each patient to achieve the maximum degree of rehabilitation1Rettig R.A. Lohr K.N. Measuring, managing and improving quality in the end-stage renal disease treatment setting.Am J Kidney Dis. 1994; 24: 228-234Abstract Full Text PDF PubMed Scopus (13) Google Scholar. At present, a large number of trials throughout the world that study different aspects of the treatment of renal failure include periodic assessments of QoL as one of the basic parameters to be considered on evaluating outcomes. Including QoL indicators in patient monitoring is important not only because it is a basic part of the concept of health but also because of the close relationship between QoL, morbidity, and mortality. This relationship is obvious from the many common factors that appear when these parameters are analyzed2Ifudu O. Paul H.R. Homel P. Friedman E.A. Predictive value of functional status for mortality in patients on maintenance hemodialysis.Am J Nephrol. 1998; 18: 109-116Crossref PubMed Scopus (90) Google Scholar, 3Deoreo P.B. Hemodialysis patients assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance.Am J Kidney Dis. 1997; 30: 204-212Abstract Full Text PDF PubMed Scopus (399) Google Scholar, 4McClellan W. Anson C. Birkeli K. Tuttle E. Functional status and quality of life predictors of early mortality among patients entering treatment for end stage renal disease.J Clin Epidemiol. 1991; 44: 83-91Abstract Full Text PDF PubMed Scopus (157) Google Scholar. Survival is greater in patients with a better QoL, better performance status and less morbidity. This becomes even more important in elderly patients: in some studies, psychosocial and functional factors are shown to be the most important predictors of survival5Kutner N.G. Lin L.S. Fielding B. Brogan D. Hall D.W. Continued survival of older hemodialysis patients: investigation of psychosocial predictors.Am J Kidney Dis. 1994; 24: 42-49Abstract Full Text PDF PubMed Scopus (53) Google Scholar,6Westlie L. Umen A. Nestrud S. Kjellstrand C. Mortality, morbidity and life satisfaction in the very old dialysis patients.Trans Am Soc Artif Intern Organs. 1984; 30: 21-28PubMed Google Scholar. This paper will briefly review the factors affecting the quality of life of renal failure patients receiving the various treatment options available as they proceed through the various stages of their disease: predialysis, dialysis and transplant. The number of studies assessing the QoL of patients prior to initiating dialysis therapy is much lower than studies of patients on dialysis. However, there are sufficient data on the impact of factors such as the degree of renal insufficiency, anemia, comorbidity, and early control by a multidisciplinary team. Many of the factors affecting QoL during dialysis already exist in these early stages and suitable management of these factors has an influence on the course subsequently followed by patients. The glomerular filtration rate (GFR) at which the QoL starts to deteriorate is not precisely defined. It varies considerably depending on the underlying disease. One study of 1284 patients with different degrees of renal function concludes that renal insufficiency is associated with a decrease in the quality of life and an increase in the severity and frequency of symptoms and psychological distress, and that these symptoms' severity is correlated with GFR7Rocco M.V. Gassman J.J. Wang S.R. Kaplan M. Cross-sectional study of Quality of Life and symptoms in chronic renal disease patients. The modification of diet in renal disease study.Am J Kidney Dis. 1997; 29: 888-896Abstract Full Text PDF PubMed Scopus (110) Google Scholar. Comorbidity appears as a significant factor in several studies, such as that performed by Harris et al on a population of 260 patients. The lowest QoL scores are obtained in patients with the greatest number of associated diseases, women, unemployed people and people with low education and income levels8Harris L.E. Luft F.C. Rudy D.W. Tierney W.M. Clinical correlation of functional status in patients with chronic renal insufficiency.Am J Kidney Dis. 1993; 21: 161-166Abstract Full Text PDF PubMed Scopus (96) Google Scholar. The Spanish Study Group of the Quality of Life in Chronic Renal Failure performed a study on 103 predialysis patients. Plasma creatinine was 5.8 ± 1.5 mg/dL. Patients with a higher degree of comorbidity had significantly lower scores on the physical and overall dimensions of the Sickness Impact Profile (SIP) (abstract; Nephrology 3 (Suppl 1): S309, 1997). The role played by anemia is well-established. With the growing use of recombinant human erythropoietin (rHuEPO) in the last 10 years, a large number of studies have been published showing a significant improvement in various aspects such as functional capacity, well being, level of energy and neurocognitive function in treated patients9The USA Recombinant Human Erythropoietin Predialysis Study Group Double-blind, placebo-controlled study of the therapeutic use of rHuEPO for anemia associated with chronic renal failure in predialysis patients.Am J Kidney Dis. 1991; 25: 548-554Google Scholar,10Valderrabano F. Erythropoietin in chronic renal failure.Kidney Int. 1996; 50: 1373-1391Abstract Full Text PDF PubMed Scopus (80) Google Scholar. One of the most conclusive studies was the multicenter study carried out by Revicki et al. These authors compared a group of 43 predialysis patients treated with increasing doses of rHuEPO who attained a hematocrit of approximately 35%, with another group of 40 untreated patients with a similar degree of renal function. The QoL was assessed periodically using several instruments. In the treated group of patients, a significant improvement in energy, physical function, activity at home, social activity and cognitive function was observed in parallel with the increase of hematocrit11Revicki D.A. Brown R.E. Feeny D.H. Henry D. Teehan B.P. Rudnick M.R. Benz R.L. Health-related quality of life associated with rHuEPO therapy for predialysis chronic renal disease patients.Am J Kidney Dis. 1995; 25: 548-554Abstract Full Text PDF PubMed Scopus (255) Google Scholar. The Spanish Group carried out a prospective study on 103 predialysis patients. Seventy-two were treated with subcutaneous rHuEPO and 31 were not treated. In the treated group, the hematocrit increased from 24.8 ± 2.7% to 31.4 ± 5% after three months, accompanied by a significant improvement in the Karnofsky Index and the three dimensions of the Sickness Impact Profile (SIP) Figure 1. The categories of the SIP in which the improvement is most marked were sleep, emotional status, body movement, sociability and mobility [abstract; Nephrology 3(Suppl 1):S309, 1997]. In the untreated group, the hematocrit was 29.8 ± 4.2% at baseline and 28.9 ± 4.5% after three months and no changes were seen in the QoL scores. According to our data, the hematocrit is directly related with the physical dimension of the SIP. The optimal hematocrit level is currently a subject of debate. In hemodialysis patients, there is already evidence that, in many cases, close to normal values are the most beneficial. There are no data with regard to predialysis patients, but it seems reasonable to ask whether it makes sense to let patients develop symptomatic anemia or whether it would be best to prevent onset of anemia by giving rHuEPO and iron in earlier stages of the disease. Recently, Silverberg et al drew attention to the untapped potential of rHuEPO and iron therapy in such patients12Silverberg D. Blum M. Peer G. Iaina A. Anemia during the predialysis period: a key to cardiac damage in renal failure.Nephron. 1998; 80: 1-5Crossref PubMed Scopus (33) Google Scholar. In the United States and Japan, the number of patients with hematocrits of 24% at initiation of dialysis and who were under the care of a nephrologist is still high, and it is similar to that of patients whose care is not supervised by nephrologists. In Europe in 1993, an average of 40% of patients had spent the last three years before starting dialysis with hemoglobin levels below 9 g/dL12Silverberg D. Blum M. Peer G. Iaina A. Anemia during the predialysis period: a key to cardiac damage in renal failure.Nephron. 1998; 80: 1-5Crossref PubMed Scopus (33) Google Scholar. The timing and quality of care in the predialysis phase is currently acknowledged to be a decisive factor in the patients' morbidity, mortality and QoL. At this time, adequate treatment includes interventions that may slow down the progression of renal failure, manage the complications of uremia (anemia, high blood pressure, osteodystrophy, malnutrition), choose the dialysis technique and its preparation (vascular access, peritoneal catheter), start the replacement therapy in adequate time, and, last but not least, include the patient in a high-quality rehabilitation program. This program should cover a number of aspects, such as information and psychological support for the patient and his/her family, continuation with his/her job, if applicable, and maintenance of the social and family roles. These treatments maintain the highest possible degree of functional capacity, above all in the most disabled patients13Hood S.A. Sondheimer J.H. Impact of Pre-ESRD management on dialysis outcomes: a review.Semin Dial. 1998; 11: 175-180Crossref Google Scholar, 14Arora P. Obrador G.T. Ruthazer R. Kausz A.T. Meyer K.B. Jenuleson C.S. Pereira B.J.G. Prevalence, predictors and consequences of late nephrology referral at a tertiary care center.J Am Soc Nephrol. 1999; 10: 1281-1286PubMed Google Scholar, 15Latham C.E. Is there data to support the concept that educated, empowered patients have better outcomes?.J Am Soc Nephrol. 1998; 9: S141-S144PubMed Google Scholar. Patients included in this type of program continue for longer before requiring dialysis therapy and their treatment compliance is better16Binik Y.M. Devins G.M. Barre P.E. Guttmann R.D. Hollomby D.J. Mandin H. Paul L.C. Hons R.B. Burgess E.D. Live and learn: Patient education delays the need to initiate renal replacement therapy in ESRD.J Nerv Ment Dis. 1993; 181: 371-376Crossref PubMed Scopus (92) Google Scholar. Early death, morbidity and hospitalization requirements are greater in patients referred at later stages in their disease15Latham C.E. Is there data to support the concept that educated, empowered patients have better outcomes?.J Am Soc Nephrol. 1998; 9: S141-S144PubMed Google Scholar. Sesso studied 113 patients approximately one month after starting dialysis. The QoL is worse in the patients controlled at a late stage by the nephrologists than those who had been diagnosed and under treatment for more than six months. The most significant differences are found in depression, relationships, frustration and satisfaction with life, and are particularly marked in elderly patients17Sesso R. Yoshihiro M.M. Time of diagnosis of chronic renal failure and assessment of quality of life in hemodialysis patients.Nephrol Dial Transplant. 1997; 12: 2111-2115Crossref PubMed Scopus (62) Google Scholar. There are many barriers that impede early access by patients and adequate preparation. It is likely that one of the most serious is an insufficient degree of coordination between primary medical care and hospital care, and actions tending to improve this coordination may be useful. In our department, the percentage of patients requiring an initial emergency dialysis with a temporary vascular access has ranged around 15% in recent years, in some cases due to the absence of prior symptoms or refusal by the patient but also, in a significant number of cases, due to inadequate management by their primary center18Gomez Campera F. Jofre R. Tejedor A. Lopez Gomez J.M. La primera diálisis en el paciente con insuficiencia renal crónical. ¿Control de calidad de nuestra atención primaria?.Nefrología. 1994; XIV: 244Google Scholar. There are many studies that analyze the QoL of dialysis patients, most of whom are on hemodialysis. The number of patients studied who are on peritoneal dialysis is much lower. Due to their specific features, diabetic patients, elderly patients and those who return to dialysis after failure of a renal graft have also been the subject of various studies. In the classic National Kidney Dialysis and Kidney Transplantation Study performed on 859 patients, the functional measures of dialysis patients were worse than those of the normal population, although the subjective measures were less affected19Evans R. Manninen D. Garrison L. The quality of life of patients with end-stage renal disease.New Engl J Med. 1985; 312: 553-559Crossref PubMed Scopus (856) Google Scholar. Transplant, home dialysis, and peritoneal dialysis patients obtained better results than patients on hospital hemodialysis. These early data have been confirmed in later studies. The National Kidney Foundation has carried out a prospective, two-year study on 1000 patients using the 26-item Short Form Health Survey Questionnaire (SF-36), comparing their results with those of a healthy population composed of 2474 subjects. The physical function is the most severely affected while the mental function is the closest to normal. In its data, the performance status has the same predictive value on mortality and hospitalization as Kt/V and normalized protein catabolic rate (nPCR)3Deoreo P.B. Hemodialysis patients assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance.Am J Kidney Dis. 1997; 30: 204-212Abstract Full Text PDF PubMed Scopus (399) Google Scholar. With each 5-point increase in the physical function, the likelihood of survival increased 10%. The impact of the mental function was less, ranging between 2 and 5.8%. The scores of the patients analyzed by age group are very similar to those obtained by other groups, suggesting that these patients answer to a particular “profile”20Kutner N.G. Renal rehabilitation: where are the data? A progress report.Semin Dial. 1996; 9: 387-389Crossref Google Scholar. In 1993, the Spanish Group carried out a study to assess the QoL of dialysis patients, seeking to identify the factors that had the greatest influence on the QoL21Moreno F. Lopez Gomez J.M. Sanz Guajardo D. Jofre R. Valderrabano F. The Spanish Cooperative Renal Patients Quality of Life Study Group: Quality of life in dialysis patients. A Spanish multicentre study.Nephrol Dial Transplant. 1996; 11: 125-129Crossref PubMed Scopus (116) Google Scholar. In this study, 1013 patients, currently stable on dialysis, were chosen randomly from 42 centers. The quality of life instruments used were the self-answered Karnofsky Index (KI) and the SIP. Data were obtained on age, sex, etiology of the renal failure, time on dialysis, and characteristics of the technique, failed prior transplant and rHuEPO therapy, as well as employment, education and socioeconomic status. Comorbidity was assessed using Friedman's Index, which controls for the presence and severity of 13 possible diseases. The presence of blindness, claudication or diabetes was recorded. The urea, creatinine, hemoglobin, hematocrit, Kt/V and PCR values were included. Of the patients in the study, 56% were men, 44% women; 41% were older than 60 years; 96% were undergoing hemodialysis and 4% peritoneal dialysis; 18% of the patients had undergone a previous, unsuccessful renal graft. The results of the QoL indicators are shown in Table 1. The overall mean for all patients indicates a moderate impairment of the QoL; 26% obtained a score equal or greater than 20 in the global dimension of the SIP and 31% obtained 60% or less on the KI, indicating a significant effect by the disease. The most severely affected areas of the SIP are work, free time and hobbies, home activities, and sleep and rest.Table 1QoL indicators in dialysis patients: Mean values of physical, psychosocial, and global dimensions in the SIP in dialysis patientsaN = 1013MeanTypical SDPercentile2575Karnofsky Indexb31% patients <6073156090SIP Physical dimension1213217Psychosocial dimension1414420Global dimensionc26% patients SIP> 201512621a N = 1013b 31% patients <60c 26% patients SIP> 20 Open table in a new tab There were no differences in the QoL related to the technique, type of buffer or membrane, Kt/V or PCR. Higher hemoglobin levels were related to better QoL scores on physical and global dimension of the SIP. A higher socioeconomic or educational status was associated with better scores. Elderly patients and those with a higher degree of comorbidity showed a lower functional capacity and a greater impact of the disease on their QoL. Female gender and diabetes are factors that correlate negatively with the global and physical dimensions of the SIP. The Italian group DIA-QoL, when administering the SF-36 to 300 patients, also observed lower scores in women, while age and diabetes were the physical aspects having the greatest effect. They found a relationship between albumin levels and the questionnaire's physical dimensions. Upon comparing their data with age-matched groups from the general population, dialysis patients obtained lower scores, particularly in the physical aspects. In the case of elderly patients, the differences are less, particularly in the mental aspects23Canadian Erythropoietin Study Group Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving hemodialysis.Br Med J. 1990; 300: 573-578Crossref PubMed Google Scholar. Diabetic patients obtain poorer results than nondiabetic patients for all age groups in all the studies. In their case, comorbidity is the main determinant. Diabetic patients comprise a more vulnerable patient group and special effort should be devoted to them to improve their rehabilitation21Moreno F. Lopez Gomez J.M. Sanz Guajardo D. Jofre R. Valderrabano F. The Spanish Cooperative Renal Patients Quality of Life Study Group: Quality of life in dialysis patients. A Spanish multicentre study.Nephrol Dial Transplant. 1996; 11: 125-129Crossref PubMed Scopus (116) Google Scholar,22Mingardi G. Cornalba L. Cortinovis E. Ruggiata R. Appolone G. DIAQOL Group Health-related quality of life in dialysis patients. A report from an Italian study using the SF-36 Health Survey.Nephrol Dial Transplant. 1999; 14: 1503-1510Crossref PubMed Scopus (166) Google Scholar. In the above-mentioned study carried out by the Spanish Group, hemoglobin levels are significantly related with the global and physical dimensions of the SIP, as Figure 2 shows. The role of anemia in the QoL, as appearing in our data, is well known. The results of several multicenter studies on the QoL of rHuEPO-treated patients were published the early 1990s23Canadian Erythropoietin Study Group Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving hemodialysis.Br Med J. 1990; 300: 573-578Crossref PubMed Google Scholar, 24Evans R.W. Rader B. Manninen D.L. Cooperative Multicenter Epo Clinical Trial Group The quality of life of hemodialysis recipients treated with recombinant human erythropoietin.JAMA. 1990; 263: 825-830Crossref PubMed Scopus (390) Google Scholar, 25Sundal E. Businger J. Kappeler A. Treatment of transfusion-dependent anemia of chronic renal failure with recombinant human erythropoietin.Nephrol Dial Transplant. 1991; 6: 955-965Crossref PubMed Scopus (36) Google Scholar. The target hematocrits varied but, in all studies, the patients' functional capacity, energy and activity level, sleep, mobility, appetite, social relationships, perceived state of health and decrease in the standard list of symptoms, such as dyspnea, anxiety and muscle fatigue, improved significantly. Beusterien et al studied the changes observed in the SF-36 in 484 patients who started treatment with rHuEPO and compared them with another group of 520 patients already under treatment. At baseline, untreated patients scored lower than treated patients. However, the differences narrowed progressively as the hematocrit increased26Beusterien K.M. Nissenson A.R. Port F.K. Kelly M. Steinwald B. Ware J.E. The effects of recombinant human erythropoietin on functional health and well-being in chronic dialysis patients.J Am Soc Nephrol. 1996; 7: 763-773PubMed Google Scholar. In Spain, Moreno et al compared the QoL of 57 patients starting treatment with rHuEPO with a control group of 29 patients who did not require therapy; in the treated group, the correction of the anemia was associated with a significant improvement on all three dimensions of the SIP27Moreno F. Valderrabano F. Aracil F.J. Perez R. Influence of hematocrit on quality of life on hemodialysis patients.Nephrol Dial Transplant. 1994; 9: 1034Google Scholar. The optimal hematocrit to be maintained in dialysis patients continues to be the subject of debate. Five years ago, Eschbach postulated that patients were insufficiently treated, with target hematocrits around 30% in most centers. Among the possible causes for this would be the lack of objective studies on the benefits of higher hemoglobin levels, an incorrect assessment of the morbidity associated with anemia, and the high cost of rHuEPO28Eschbach J.W. Erythropoietin: the promise and the facts.Kidney Int. 1994; 45: S70-S76Google Scholar. The hematocrit level currently recommended by the National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) guidelines is 33–36%29Eknoyan G. Levin N. Clinical Practice Guidelines: Final Guideline Summaries from the Work Groups of the National Kidney Foundation-Dialysis Outcomes Quality Initiative. National Kidney Foundation, New York1997Google Scholar. Studies performed in small groups of patients who received treatment to increase the hematocrit up to 42% showed improvements in QoL, exercise capacity and heart function (abstract; J Am Soc Nephrol 4:8, 1993), and an improvement in cerebral blood flow30Metry G. Wikström B. Valind S. Sandhagen B. Linde T. Beshara S. Längstrom B. Danielson B.G. Effect of normalization of hematocrit on brain circulation and metabolism in hemodialysis patients.J Am Soc Nephrol. 1999; 10: 854-863PubMed Google Scholar. Our group has performed a prospective, controlled study on the effects of restoring normal hematocrit values on QoL31F. Moreno, J.M. Lopez gomez, R. Jofre, D. Sanz, F. Valderrabano, and the Spanish Cooperative Group: Normalization of hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. J Am Soc Nephrol. in pressGoogle Scholar. Stable patients aged between 18 and 65 years and hematocrits between 28 and 35% were included. The target was a 5-point increase in the hematocrit. The exclusion criteria were diabetes, uncontrolled arterial hypertension, malfunction of the vascular access, severe comorbidity, history of heart failure, ischemic heart disease, stroke or seizures. Doses of rHuEPO were doubled in patients receiving less than 60 IU/kg per week and were increased 50% in those receiving more than 60 IU/kg per week. The SIP and the KI were used as QoL indicators and the study's duration was six months. One hundred and fifty-six patients were included in the study. Of these, 7 withdrew due to transplant, 12 failed to show at least a 4-point increase in hematocrit figures, and 10 were lost to follow-up. Twelve patients were censored due to adverse effects, and 115 completed the six months follow-up period. The mean age of the patients was 44 ± 15 years and the duration of dialysis therapy before the study was 37 ± 40 months. The baseline hematocrit was 31 ± 0.9%, and increased to 39 ± 2% after six months. A significant improvement was observed in all three dimensions of the SIP Figure 3 and the KI. The hospitalization rate fell significantly. This has also been reported in other studies32Xia H. Ebben J. Ma J.Z. Collins A. Hematocrit levels and hospitalization risks in hemodialysis patients.J Am Soc Nephrol. 1999; 10: 1309-1316PubMed Google Scholar. Three patients were censored from the study due to uncontrolled arterial hypertension and nine due to fistula thrombosis; these rates are in line with usual findings. This study shows that, in selected patients, restoring normal hematocrit values induces a marked improvement of the QoL, without adverse effects. The results of the North American multicenter study published recently by Besarab et al33Besarab A. Bolton W.K. Browne J.K. Egrie J.C. Nissenson A.R. Okamoto D.M. Schwab S.J. Goodkin D.A. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoietin.N Engl J Med. 1998; 339: 584-590Crossref PubMed Scopus (1771) Google Scholar show the need for further research in this area. They studied 1233 dialysis patients with a background of ischemic heart disease or congestive heart failure. The rHuEPO dose was increased in one half of the group to hematocrit values of 42% while the other half was kept at hematocrit values of 30%. The QoL, as assessed with the SF-36, improves 0.6 points on the physical level for each percentage point increase in the hematocrit, without any significant changes in the other scores. Mortality and the frequency of myocardial infarctions after 2 years were higher in the normal hematocrit group (normal/low risk rate 1.3), and consequently the study was stopped. However, in both groups, the mortality rate was lower at high hematocrit levels. After analyzing their data, the authors of this study were unable to find an explanation for their results, concluding that restoring normal hematocrit values is not to be recommended in such patients33Besarab A. Bolton W.K. Browne J.K. Egrie J.C. Nissenson A.R. Okamoto D.M. Schwab S.J. Goodkin D.A. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoietin.N Engl J Med. 1998; 339: 584-590Crossref PubMed Scopus (1771) Google Scholar. Given these conflicting results, the optimal hematocrit to be targeted with rHuEPO has yet to be defined. In theory, it would be the value that maximizes survival, cardiovascular function and daily life activities with minimal risk. The different organs may respond differently to improvements in the degree of anemia and the best hematocrit for the brain need not necessarily be the best for the myocardium. Furthermore, different patient groups (diabetics, elderly patients, patients with heart disease, sedentary/active patients) may have different requirements34Nissenson A.R. Besarab A. Bolton W.K. Goodkin D.A. Schwab S.J. Target hematocrit during erythropoietin therapy.Nephrol Dial Transplant. 1997; 12: 1813-1816Cross" @default.
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