Naturally Occurring Higher Hemoglobin Concentration Does Not Increase Mortality among Hemodialysis Patients

Abstract

A small percentage of hemodialysis patients maintain higher hemoglobin concentrations without transfusion or erythropoietic therapy. Because uncertainty exists regarding the effects of higher hemoglobin concentration on mortality and quality of life among hemodialysis patients, studying this group of patients with sufficient endogenous erythropoietin may provide additional insights. The prospective, observational Dialysis Outcomes and Practice Patterns Study provides an opportunity to investigate this group. Among 29,796 patients in 12 nations, 545 (1.8%) maintained hemoglobin concentrations Ͼ12 g/dl for 4 months without erythropoietic support. This subset tended to be male, to have a longer duration of end-stage renal disease, and to not dialyze via a catheter. Cystic disease as the underlying cause of renal failure was over-represented in this group but was present in only 25%. Lung disease, smoking, and cardiovascular disease were associated with increased likelihood of naturally higher hemoglobin concentration. Quality-of-life scores were not higher among this subset compared with the other patients. Unadjusted mortality risk for patients with hemoglobin Ͼ12 g/dl and no erythropoietic therapy was lower than for the other patients, but after thorough adjustment for case mix, there was no difference between groups (relative risk, 0.98; 95% CI 0.80 to 1.19). These data show that naturally occurring hemoglobin concentration Ͼ12 g/dl does not associate with increased mortality among hemodialysis patients.

Effect of long period treatment with erythropoiesis stimulating agents on clinically and laboratory parameters in hemodialysis autosomal dominant polycystic kidney disease patients

“…Our non-ESA patients had lower values of ferritin than the ones in the ESA group, a result that matches others (2,12). TSAT was also reduced in our group, as was in another study, while others did not observe a significant difference or did not find TSAT values as predictive factors for non-ESA status (2,3,12). The study by Gaweda et al analyzed how ferritin and TSAT values influence Hb increase after ESA therapy in patients on HD.…”

“…Increased ferritin in ESRD was also associated with a partial, inefficient response to ESA, and more severe anemia (18). Our non-ESA patients had lower values of ferritin than the ones in the ESA group, a result that matches others (2,12). TSAT was also reduced in our group, as was in another study, while others did not observe a significant difference or did not find TSAT values as predictive factors for non-ESA status (2,3,12).…”

“…The use of a percutaneous HD catheter was associated with a lower likelihood of being part of the non-ESA group. The presence of ADPKD correlated with higher levels of Hb than other underlying kidney diseases and a higher chance of patients belonging to the non-ESA group (2,10). In another study on 1318 HD patients (1307 in the ESA group and 11 in the non-ESA group), the non-ESA group had, again, a higher proportion of men, with a higher dialysis vintage, a higher prevalence of ADPKD, but also an increased level of endogenous EPO.…”

“…Naturally occurring Hb concentrations above 12 g/dL do not associate with increased mortality in HD patients. The absence of anemia may be related, in part, to a higher capacity of patients to produce erythropoietin (EPO) (2). The presence of renal or hepatic cysts was associated with increased EPO synthesis and the absence of anemia in patients on HD (3).…”

Safety Issues in Iron Treatment in CKD

“…1,4 In addition, the minority of end-stage renal disease (ESRD) patients who naturally maintain normal hemoglobin levels without requiring erythropoiesis-stimulating agents (ESAs) do not experience increased mortality. 5 Despite high doses of ESA and intravenous (IV) iron products, only a minority of patients randomized to the normal (21% in Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease (CHOIR)) or near-normal hemoglobin (38% in Cardiovascular Reduction Early Anemia Treatment Epoetin β (CREATE)) groups achieved the target. [1][2][3] As a result of implementation of the bundling reimbursement system in the United States and the high cost of ESAs, the ESA dosing has decreased and IV iron has increased and ferritin levels have continued to increase.…”