What hemoglobin level is too low?

My dad has been on PD about three months now and in January experienced critical anemia, his hemoglobin was down to 5 and he was hospitalized to have five units of whole blood transfused. He was released from the hospital when his hemoglobin got up to 8. He was away on vacation when this happened so I know those doctors released him at the earliest possible stable point so that he could travel back home to his own doctors. Now back home in the care of his nephrologist, my dad is up to 9. The Dr. won’t do another transfusion to raise this and, apparently my dad’s cardiologist’s hands are tied–he can’t prescribe the transfusion because the anemia seems to be related to dialysis/kidney failure. This upsets me. I don’t think 9 is high enough and I know that anemia is strongly linked to increased mortality rates in dialysis patients. Can anyone give me some frame of reference on this? I can find plenty of information that gives me the high limit for hemoglobin–that is an issue since insurance companies don’t want to cover “unnecessary” transfusions or epogen treatments for hemoglobin levels above 12. But what is the lowest acceptable level? I think he should be at 10 or 11. Am I right? And if so, what can we do? I wonder if this is an issue only in the U.S.

Hi Babboo,

Right now, the target hemoglobin range is 10-12 (with the new FDA “Black Box” warning keeping doctors from letting folks go above 12). Less than 10 isn’t good, as you’ve noted, but transfusions are not the best way to raise hemoglobin. Isn’t your dad getting some form of EPO? (EPOGEN®, Aranesp®, or Procrit®). It takes some time for EPO to work–typically at least a few weeks–but he should have received it in the hospital and should be getting it every few days or weeks, depending on which drug it is.

EPO is a synthetic form of the hormone erythropoietin which is made by healthy kidneys and signals the bone marrow to make more red blood cells. It’s better to make your own than to get someone else’s–less risk of blood-borne diseases (the Red Cross is careful, but not perfect) or becoming sensitized so a transplant is more difficult.

It sounds like with a hemoglobin of 9, your dad is in the “gray zone” where no-one will give him a transfusion. Please do ask him about EPO (under its various names–it’s only offered as an injection, so he should remember it). You can also learn more in the Anemia module of Kidney School at http://www.kidneyschool.org. Please note, though, that we are updating Kidney School right now, and research has not supported a link between anemia and heart damage (LVH) in people with kidney disease. LVH is caused by high blood pressure. We’ll be putting up the new, updated Kidney School soon!

HI mine went down to 4.9 at one point and I got infusion in hospital and the epo shot while there…
For me they realized me at 8 but had me go for bloodtest 2 weeks later and mine was up to 10.9
I think Dori may be right your dad probably got the shot in hospital but hopefully dr is following up.
Hope your dad is feeling better

Thanks. My dad is getting Epogen, several times a week and right now he is at 9.7. I am just really uncomfortable with this. I have heard that the body become resistent to Epogen over time. Then what? I will check Kidney School but if anyone knows, please advise. Thank you.

EPOGEN resistance is possible–but it’s not necessarily due to the EPO itself (which is a replacement, after all, of a hormone the body makes less (or none) of in kidney failure). EPO resistance may actually be caused by malnutrition and/or inflammation–both of which lower the chances of survival.

EPO resistance, then, is sort of the “canary in the mine”–it should be a clue that something ELSE is wrong. But folks have been on EPO since it first came out in 1989, and they don’t necessarily ever become resistant to it if they are otherwise in good health except for kidney failure.

Hi my hemaglobin went down to a 3 and I went to the hospital and I got 5 units of blood and my doctor did not recommend epogen at all because of the dependency but i have been taking procrit for the past month and my hemaglobin is up to a 10

Epogen and Procrit are exactly the same drug. Amgen makes them both. Procrit is sold by Ortho for people who have cancer or predialysis CKD. Amgen sells Epogen for use by people who are on dialysis.

There are no “dependency” issues with either drug–it is simply replacement of a hormone your body makes less of as your kidneys fail.