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**2** 

*Australia* 

**Association Between Haemoglobin** 

Roshini Malasingam, David W. Johnson and Sunil V. Badve

*Australasian Kidney Trials Network, The University of Queensland, Brisbane, QLD,* 

Anaemia is a common complication of chronic kidney disease (CKD). The underlying physiology related to anaemia in CKD is secondary to reduction in endogenous erythropoietin as the glomerular filtration rate (GFR) declines. The introduction of erythropoiesis stimulating agents (ESA) has revolutionized the management of anaemia in CKD, leading to substantial reductions in the blood transfusion requirements, improvement in energy and physical function and small improvements in health-related quality of life (Clement et. al., 2009; Eschbach et. al., 1987; Gandra et. al., 2010). Targeting higher haemoglobin with ESA therapy has been associated with increased risks of stroke, vascular access thrombosis, hypertension and possibly death (Badve et. al., 2011; Besarab et. al., 1998; Palmer et. al., 2010; Pfeffer et. al., 2009; Phrommintikul et. al., 2007; Singh et. al., 2006). The current KDOQI Clinical Practice Guideline recommends a haemoglobin target of 11-12g/dL. However, a substantial proportion of non-dialysis and dialysis CKD patients exhibit fluctuations in the haemoglobin levels, also known as haemoglobin variability. There is an emerging body of evidence demonstrating an association between haemoglobin variability and mortality in CKD patients treated with ESAs. Maintaining haemoglobin levels within narrow target range remains a major challenge in clinical practice. The aim of this chapter is to review the definition, prevalence, risk factors of haemoglobin variability, and its impact on survival, provide recommendations where possible

The definition of haemoglobin variability is not entirely clear and various studies have used different definitions. Intra-individual haemoglobin variability is defined as the fluctuation of haemoglobin above or below (Kalantar-Zadeh & Aronoff 2009) *or* even within the target range over time. Methods to quantify haemoglobin variability are summarised below.

1. Standard deviation of the differences between observed haemoglobin values and haemoglobin slope which represents the mean haemoglobin change over time (Yang et.

**1. Introduction** 

and suggest directions for future research.

**2. Haemoglobin variability** 

**2.1 Definition** 

al., 2007).

**Variability and Clinical Outcomes** 

**in Chronic Kidney Disease** 

*Princess Alexandra Hospital, Brisbane, QLD,* 

