For Hb concentrations ��130g/L, a trend towards higher mortality risk was observed (RR=2.356, never 95% CI 0.953�C5.822, P = 0.063), but it did not reach statistical significance. Anemia is associated with an increased risk of morbidity and mortality principally due to cardiac disease and stroke [13, 14]. Hb concentration <100g/L is independent risk factor of cardiovascular diseases for dialysis patients [15]. DOPPS study showed that higher Hb concentrations were associated with decreased relative risk for mortality [11]. On the other hand, clinical trials showed that maintenance of Hb levels above 130g/L may be associated with increased morbidity and mortality in dialysis. A recent meta-analysis indicated increased mortality at higher Hb target [12].

A trend towards a higher mortality risk was observed for patients with Hb concentrations >130g/L in our study.3.5. Hemoglobin Variability in Lithuanian HD PatientsSince the introduction of ESA, most of the clinical trials with ESA therapy have focused on Hb targets in CKD patients; however, there is a shortage of clinical trials studying the optimal strategy for Hb monitoring in patients treated with ESA and interventions to reduce Hb variability. Several factors affect Hb variability, including those that are drug related, such as pharmacokinetic parameters, clinical practice guidelines, treatment protocols, and reimbursement policies. Strategies that consider each of these factors and reduce Hb variability may be associated with improved clinical outcomes [16].

There is conflicting evidence on the effect of Hb variability on mortality with some studies demonstrating a strong association and others showing no association with mortality.We evaluated Hb concentrations and ESA doses in 100 patients��56 (56%) men and 44 (44%) women. The mean age of patients was 61.88 �� 14.8 years (31�C84). Mean time from the start of dialysis until inclusion into the study was 4.75 �� 4.33 years. The new anemia management algorithm in Lithuania (August 2011) gave a clear rise in the Hb concentrations during the second half-year of 2011 (Figure 3). We found that Hb concentrations increased significantly with a new algorithm, though mean doses of ESA remained unchanged (11073.17U/week versus 11425U/week; P = 0.491).Figure 3Mean hemoglobin concentrations during 2011 year. Influence of a new anemia management algorithm, certified in Lithuania August 2011.

We looked in detail to each month (01/2011�C06/2011) Hb concentrations and found that only 17.1% of patients during this period had Hb in the target range according to local algorithm (100�C105g/L), 50.2% of patients Drug_discovery had Hb <100g/L, and 32.7% had Hb >105g/L. A big part of our patients exhibited fluctuations in the Hb levels corresponding to literature data where we found that 80�C90% of ESRD patients on dialysis exhibit fluctuations in the Hb levels, known as Hb variability [16�C19].