Through the Looking Glass

Abstract

The most recent National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease report, released in May 2006, has led to intense debate and scrutiny in both the scientific and the lay press. At issue are the process and the timing of the report, the role of participants and of industry, and the quality of the data used in making recommendations. Suggestions in both the press and medical journals that vested interests might have resulted in recommendations that might be unwarranted and harmful have reflected adversely on the guidelines, irrespective of the good intentions of those who wrote them. In light of this media maelstrom, it is worthwhile to consider the history of both guidelines and the problem of anemia in chronic kidney disease (CKD). It has been nearly two decades since Eschbach et al. (1) reported the results of phase 1–2 study in 25 patients and then a phase 3 study (2) that demonstrated that erythropoietin could correct anemia in patients who receive dialysis, averting the need for transfusion and its attendant risks. Since those first clinical studies about erythropoietin, the course of severe anemia in CKD, as well as in other diseases, has been greatly altered in a generally positive direction. In recent years, the question has focused not on whether to use agents that stimulate erythropoiesis, but how best to use such agents in our patients. The data necessary to inform the optimal correction of anemia have not been definitive, and new trials were designed to address the issue. Concomitantly, guidelines that were based on available data, revised over time, have played a prominent role in shaping our medical decisions about anemia and other aspects of renal disease. The most recent version of the KDOQI …