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    "textoCompleto" => "<p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">There is little information about the actual implementation of Clinical Practice Guidelines on the treatment of anaemia &#40;CPGA&#41; in our country&#8217;s peritoneal dialysis &#40;PD&#41; units&#46; Since the first CPGA in 1997&#44;<span class="elsevierStyleSup">1</span> scientific societies have published more than 25 guidelines worldwide&#44; although many of them are transpositions of the European<span class="elsevierStyleSup">2</span> &#40;EBPG&#41; and American guidelines<span class="elsevierStyleSup">3&#44;4 </span>&#40;KDOQI&#41;&#46;</p><p class="elsevierStylePara">One of the most controversial aspects has been the target haemoglobin &#40;Hb&#41; levels&#46; Unfortunately&#44; few studies have been published on anaemia in PD&#46; Most major observational studies and all clinical trials on this subject have been conducted in patients on haemodialysis &#40;HD&#41; or patients with chronic kidney disease&#46; As such&#44; the guidelines extrapolate these data to PD without considering the differences between the patients&#8217; profiles and the characteristics of each technique&#46;</p><p class="elsevierStylePara">The lower limit target of 11g&#47;dl Hb has actually remained stable from 1997-2009&#46; However&#44; the upper limit has been increasing towards the standardisation of Hb figures&#44; until the EBPG 2004 guidelines&#44; which maintained the absolute maximum limit at 14g&#47;dl&#44; but indicated 12g&#47;dl for patients with previous cardiovascular events&#46; The KDOQI 2006 guidelines recommend not intentionally maintaining Hb&#62;13g&#47;dl and the 2007 update recommends a general range between 11 and 12g&#47;dl&#46; The results of the CREATE&#44; CHOIR and TREAT studies did not show any benefits from standardisation&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Many of us question the level of knowledge and acceptance of these guidelines&#44; and few data exist regarding their application in the PD of our setting&#46; Most data are taken from observational studies or foreign registries that do not suitably take into account this development over time&#46;</p><p class="elsevierStylePara">We began our study in September 2011 by surveying the heads of each unit of the Peritoneal Dialysis Centre Group &#40;PDCG&#41;&#46; 56&#37; responded with the following relevant facts&#58; only 21&#46;4&#37; of nephrologists say they do not apply any CPGA&#44; 50&#37; apply the most recent &#40;KDOQI or EBPG&#41;&#44; although they seem to prefer the European guidelines to the American guidelines &#40;3-1&#41;&#46; They also estimate that it takes an average of 3-6 months to apply these CPGA in their regular clinical practice&#46;</p><p class="elsevierStylePara">The PD Hb control targets depend largely on the management carried out by the patient&#39;s nephrologist&#44; since we have effective and safe drugs&#46; Today it is accepted that resistance maintained to treatment with erythropoiesis stimulating agents &#40;ESA&#41; is very rare&#46; In fact&#44; only 1&#37; of HD patients presented a Hb level that is below the target level after 6 months on ESA doses equivalent to 30&#160;000 units erythropoietin&#47;week and this rate may be lower in PD&#46;<span class="elsevierStyleSup">3</span> Therefore Hb levels achieved may be a true reflection of the degree of implementation of the current CPGA at any given time&#46;<span class="elsevierStyleSup">2-4</span></p><p class="elsevierStylePara">The CPGA has a multipurpose database that collects data prospectively&#44; which has shown to be a representative sample of PD patient management in our setting&#44; the operation of which has previously been described&#46;<span class="elsevierStyleSup">6</span> It is an open database which incorporates new incident patients whose follow-up ends with the withdrawal of PD&#46; In our analysis&#44; we included 1166 patients from 2004 to 2010&#46; The characteristics of this group have been described previously&#44; but it is clear that these are younger patients with less comorbidity than their peers on HD&#46; In order to calculate the average Hb level&#44; each patient contributes a single average value from their available Hb figures and all available data for the year is used for stratification by intervals&#46; Figure 1 shows a summary of the change in values&#46; Comorbidy of patients&#44; as measured by the Charlson index&#44; was not significantly different between the different years &#40;3&#46;2 to 3&#46;3&#41; and the age increased from 53&#46;8 in the first year to 56&#46;22 in the last&#44; with a progressive linear trend&#46; There were no significant changes in ESA dose measured by weight&#46;</p><p class="elsevierStylePara">We have previously published that patients begin PD with better anaemia control than their peers on HD presented by the MAR study&#46;<span class="elsevierStyleSup">6&#44;7</span> The failure to achieve targets also seems to be more frequent due to high Hb than to low Hb&#46;<span class="elsevierStyleSup">6</span> This may reflect a sense of security in the management of younger and less comorbid patients and patients with less cardiovascular involvement than their counterparts on HD and those who also have a high early withdrawal rate due to transplantation&#46; PD does not subject patients to ultrafiltration&#44; which causes haemoconcentration&#44; and these patients also have a more active and socially integrated life&#46; All this seems to shift the risk&#47;benefit analysis towards higher Hb levels&#46; We did not find data showing that higher levels of Hb are harmful and mortality for this group is below that observed in national registries&#46;<span class="elsevierStyleSup">6&#44;8</span></p><p class="elsevierStylePara">Our data show that the average Hb levels have dropped over the years &#40;11&#46;8g&#47;dl in 2010 vs&#46; 12&#46;2g&#47;dl in 2004&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#44; and the number of patients with Hb&#62;13g&#47;dl is steadily falling &#40;14&#46;3&#37; vs&#46; 29&#46;6&#37;&#41; at the same time that there is an increase in the percentage of those with Hb&#60;11g&#47;dl &#40;24&#46;9&#37; vs&#46; 16&#46;3&#37;&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; The percentage of patients in the 11-13 range is improving year after year &#40;60&#46;8&#37; vs&#46; 54&#46;1&#37;&#41;&#46;</p><p class="elsevierStylePara">This analysis is significantly limited since we cannot analyse elements that influence anaemia management such as supporting treatments&#44; inflammation and nutrition&#44; but we consider that the data confirm what is described in the survey&#44; constituting a near future and current reference of anaemia management in our PD units and the implementation of the GPCA &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara">It is expected that this trend will continue in the coming years following the recent publication of the 2012 KDIGO guidelines&#46;<span class="elsevierStyleSup">9</span> We believe that studies about anaemia&#44; which allow specific targets to be identified for these patients in PD&#44; are necessary&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11776&#95;16025&#95;42417&#95;en&#95;t111776&#95;copy1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11776_16025_42417_en_t111776_copy1.jpg" alt="Evolution of target anaemia levels in chronic kidney disease in the clinical guidelines"></img></a></p><p class="elsevierStylePara">Table 1&#46; Evolution of target anaemia levels in chronic kidney disease in the clinical guidelines</p><p class="elsevierStylePara"><a href="grande&#47;11776&#95;16025&#95;42418&#95;en&#95;f111776&#46;jpg" class="elsevierStyleCrossRefs"><img src="11776_16025_42418_en_f111776.jpg" alt="Distribution of haemoglobin values in prevalent patients on peritoneal dialysis at the end of every year during the period analysed "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Distribution of haemoglobin values in prevalent patients on peritoneal dialysis at the end of every year during the period analysed </p>"
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