Association of Quarterly Average Achieved Hematocrit With Mortality in Dialysis Patients: A Time-Dependent Comorbidity-Adjusted Model

Messana, Joseph M.; Chuang, Chien; Turenne, Marc N.; Wheeler, John R. C.; Turner, Jason S.; Sleeman, Kathryn K.; Tedeschi, Philip; Hirth, Richard A.

doi:10.1053/j.ajkd.2008.10.047

Cited by 27 publications

(21 citation statements)

References 21 publications

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“…This suggests that the association is largely independent of its impact on anemia. Previous studies in nontransplant CKD patients have demonstrated an association between EPO resistance or reduced hematopoietic response to ESAs and poor clinical outcomes, including mortality (11)(12)(13)(14)(15)(16)(17). Resistance to endogenous EPO and mortality has also been reported in patients with chronic heart failure and patients with CKD (21,24,25,33).…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies demonstrated an association between erythropoietin (EPO) resistance or reduced hematopoietic response to erythropoiesis-stimulating agents (ESAs) and poor clinical outcomes among chronic kidney disease (CKD) patients (11)(12)(13)(14)(15)(16)(17). It has been suggested that the dose of ESA may be a frequently neglected confounder for the association between higher targeted hemoglobin and mortality in randomized trials.…”

Section: Introductionmentioning

confidence: 99%

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Serum Erythropoietin Level and Mortality in Kidney Transplant Recipients

Molnar

Tabák

Alam

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Posttransplant anemia is frequently reported in kidney transplant recipients and is associated with worsened patient survival. Similar to high erythropoiesis-stimulating agent requirements, resistance to endogenous erythropoietin may be associated with worse clinical outcomes in patients with ESRD. We examined the association between serum erythropoietin levels and mortality among kidney transplant recipients.Design, setting, participants, & measurements We collected sociodemographic, clinical, medical, and transplant history and laboratory data at baseline in 886 prevalent kidney transplant recipients (mean age 51 Ϯ 13 [SD] years, 60% men, 21% diabetics). A solid-phase chemiluminescent immunometric assay was used to measure serum erythropoietin. Cox proportional hazards regression was used to model the association between baseline serum erythropoietin levels and all-cause mortality risk.Results During the median 39-month follow-up, 99 subjects died. The median serum erythropoietin level was 10.85 U/L and hemoglobin was 137 Ϯ 16 g/L. Mortality rates were significantly higher in patients with higher erythropoietin levels (crude mortality rates in the highest to lowest erythropoietin tertiles were 51.7, 35.5, and 24.0 per 1000 patient-years, respectively [P ϭ 0.008]). In unadjusted and also in adjusted Cox models each SD higher serum erythropoietin level significantly predicted all-cause mortality: HR 1SD increase 1.22 and 1.28, respectively. In adjusted Cox models each SD higher serum erythropoietin/blood hemoglobin ratio also significantly predicted all-cause mortality: HR 1SD increase 1.32. Serum erythropoietin predicted mortality in all analyzed subgroups. ConclusionsIn this sample of prevalent kidney transplant recipients, higher serum erythropoietin levels were associated with increased mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Serum Erythropoietin Level and Mortality in Kidney Transplant Recipients

Molnar

Tabák

Alam

et al. 2011

Clinical Journal of the American Society of Nephrology

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“…The process of targeting leads to greater morbidity and mortality but, higher achieved hemoglobin levels are associated with better outcomes. [8][9][10] Shortly after the use of ESAs became widespread it was recognized that monitoring hemoglobin was preferred over monitoring hematocrit. This was subsequently formalized in the KDOQI guidelines.…”

Section: Rbc Parameters and Mortalitymentioning

confidence: 99%

“…In addition, studies of patients who are on dialysis have shown that patients with higher hemoglobin levels tend to have better survival. [8][9][10] These facts argue against the above hypothesis.…”

mentioning

confidence: 92%

The association of red blood cell parameters with mortality in a population of hemodialysis patients

Michel

2011

Dialysis & Transplantation

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BBACKGROUND AND OBJECTIVESThe targeting of higher hemoglobin levels leads to increased cardiovascular events in patients with renal disease. This study is an attempt to discover if changes in red blood cell parameters are induced by erythropoiesis‐stimulating agents, and whether these changes are associated with mortality.METHODSA retrospective study of patients on hemodialysis at two dialysis units operated by Our Lady of Lourdes Hospital, Camden, N.J., evaluating the effect of dosage of epoetin alfa on red blood cell parameters and the relationship of these parameters with all cause mortality over the course of one year.RESULTSDosage of epoetin alfa was related to red blood cell distribution width and mean corpuscular hemoglobin concentration in a statistically significant manner. Red blood cell distribution width was significantly lower in one year survivors. Quintile analysis demonstrated a relationship between red blood cell distribution width and iron saturation with one year survival. Low MCHC is a powerful predictor of short term mortality.CONCLUSIONMean corpuscular hemoglobin concentration and red blood cell distribution width are influenced by high doses of epoetin alfa. This study should serve to stimulate further investigation of the predictive role of red blood cell parameters in mortality in patients with renal disease and anemia treated with erythropoiesis stimulating agents, in an attempt to elucidate the mechanism of increased cardiovascular events in patients targeted to higher hemoglobin levels. Dial. Transplant. © 2011 Wiley Periodicals, Inc.

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“…First, we provide information about the balance required between epoetin administration and achievement of target hemoglobin levels. This may have multiple consequences, including (1) increased health benefits for patients if specific hemoglobin levels rather than targets are truly associated with improved patient outcomes (23,24); (2) facilitating achievement of CMS quality performance guidelines, which, at the current time, evaluate dialysis units on their ability to maintain hemoglobin levels between 10 and 12 g/dl (19); and (3) generation of information necessary to determine cost-effective epoetin dosing strategies. For dialysis providers, maximizing results while minimizing costs will assume greater importance after the im- Continuous data are mean Ϯ SD or median (25th to 75th percentile).…”

Section: Discussionmentioning

confidence: 99%

Nadir Hemoglobin Levels after Discontinuation of Epoetin in Hemodialysis Patients

Calvo

Miskulin

Meyer

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: In hemodialysis patients, both hemoglobin variability and targeting normalization of hemoglobin may have adverse consequences. There are few data on epoetin management in patients achieving high hemoglobin levels.Design, setting, participants, & measurements: Maintenance hemodialysis patients within Dialysis Clinic Inc. (DCI) who were treated with a 20 to 30% epoetin dose reduction versus epoetin discontinuation following achievement of a hemoglobin level of >13 g/dl were evaluated. The primary outcome was nadir hemoglobin within 2 months of epoetin reduction or discontinuation.Results: There were 2789 patients in whom epoetin was discontinued and 754 patients in whom epoetin was reduced after hemoglobin >13 g/dl. Patients treated with reduction received significantly more epoetin over the subsequent 2 months. More patients dropped below 11 (21.5 versus 10.1%) and 10 g/dl (7.2 versus 3.6%) within 2 months of discontinuing epoetin, whereas reduction was associated with more frequent nadir hemoglobin levels >12 g/dl (31.1 versus 62.8%). In multivariable models including age, ferritin, albumin, and baseline epoetin dose, discontinuation was associated with nadir hemoglobin below 10 g/dl [OR ‫؍‬ 1.91 (CI: 1.22, 2.99)], whereas reduction was associated with a hemoglobin nadir above 12 g/dl [OR ‫؍‬ 4.41 (CI: 3.63, 5.37)].Conclusions: In hemodialysis patients with baseline hemoglobin >13 g/dl, epoetin discontinuation is associated with lower epoetin use and a higher probability of reaching a hemoglobin target range of 10 to 12 g/dl within 2 months; discontinuation is also associated with a higher likelihood nadir hemoglobin <10 g/dl.

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Association of Quarterly Average Achieved Hematocrit With Mortality in Dialysis Patients: A Time-Dependent Comorbidity-Adjusted Model

Cited by 27 publications

References 21 publications

Serum Erythropoietin Level and Mortality in Kidney Transplant Recipients

Serum Erythropoietin Level and Mortality in Kidney Transplant Recipients

The association of red blood cell parameters with mortality in a population of hemodialysis patients

Nadir Hemoglobin Levels after Discontinuation of Epoetin in Hemodialysis Patients

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