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Intravenous iron treatment in hemodialysis patients improves response to recombinant human erythropoietin and facilitates achievement of targets for hemoglobin and hematocrit. Excessive treatment, however, could expose patients to risks related to iron overload and oxidative stress. Therefore, international treatment guidelines generally recommend that intravenous (i.v.) iron be discontinued when serum ferritin is >500-1,000 ng/ml. In the current review, relevant issues that inform decisions as to what levels of serum ferritin should be used as the upper limit for treatment are considered. A conclusion is reached that the current published literature is inadequate for developing evidence-based guidelines on this issue. Instead, clinical judgment is critical to properly weigh risks and benefits of i.v. iron treatment, and to determine whether iron treatment is appropriate for a given patient with higher levels of iron tests.

The introduction of recombinant human erythropoietin treatment has been one of the most important advances in the treatment of dialysis patients and others with chronic kidney disease (CKD). Treatment of CKD anemia has been shown to reduce the need for blood transfusions and to improve quality of life. However, the target hemoglobin level in treating patients is currently controversial. This is because of the recent publication of two randomized controlled studies in nondialysis CKD patients, the CREATE and CHOIR studies, as well as an accompanying meta-analysis. These studies demonstrate increase risk for death and cardiovascular complications when aiming for a hemoglobin (Hgb) level of >12 g/dl. In light of this new data, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative anemia guidelines are being revised. The Food and Drug Administration has issued a Black Box warning and indicated that hemoglobin levels do not exceed 12 g/dl. While observational data suggest a benefit for higher hemoglobin levels, these studies have limitations because of their retrospective design and the potential effect of confounding factors. Hence, reliance on observational studies to guide CKD anemia treatment is a potentially flawed and hazardous process. In this editorial we propose that the current literature does not support an upper Hgb target above 12 g/dl. We also suggest that the current reimbursement system for erythropoiesis stimulating agent treatment potentially encourages unsafe overtreatment.

For more than 15 years recombinant human erythropoietin (r-HuEPO) has been used for the treatment of renal anemia benefiting patients with improved quality of life and reduced need for blood transfusions. It is still early in the history of r-HuEPO treatment; therapy has changed little and there have been few investigations into whether current treatment strategies are optimal. Of note, current therapy makes little attempt to mimic normal erythropoietin biology. Large doses of drug are administered episodically resulting in great fluxes in serum erythropoietin levels. It is unlikely that this approach is very efficient from the erythropoietic standpoint. Furthermore the effects of these nonbiologic kinetics on extraerythroid organs that express erythropoietin receptors are unknown. In this review the current state of r-HuEPO treatment is compared to the normal biology of erythropoietin and potential pitfalls caused by divergences are explored.

Much effort has gone into improving the quality of care in end-stage renal disease (ESRD) in recent years. In particular, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) serves as a positive example. However, there are certain barriers to quality of care that may hinder such efforts. In this article we discuss obstacles to quality of care in ESRD and present potential solutions.