Low hemoglobin at hemodialysis initiation: an international study of anemia management and mortality in the early dialysis period.
anemia
chronic kidney disease
hemodialysis
hemoglobin
mortality
Journal
Clinical kidney journal
ISSN: 2048-8505
Titre abrégé: Clin Kidney J
Pays: England
ID NLM: 101579321
Informations de publication
Date de publication:
Jun 2020
Jun 2020
Historique:
received:
24
10
2018
accepted:
29
04
2019
entrez:
24
7
2020
pubmed:
24
7
2020
medline:
24
7
2020
Statut:
epublish
Résumé
Anemia at hemodialysis (HD) initiation is common. Correcting low hemoglobin (Hgb) before HD initiation may improve survival by avoiding potential harms of chronic anemia, high doses of erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron in the early HD period, and/or rapid Hgb rise. We included 4604 incident HD patients from 21 countries in the Dialysis Outcomes and Practice Patterns Study Phases 4-5 (2009-15). Because low Hgb at HD start may reflect comorbidity or ESA hyporesponse, we restricted our analysis to the 80% of patients who achieved Hgb ≥10 g/dL 91-120 days after HD start (Month 4). About 53% of these patients had Hgb <10 g/dL in Month 1 (<30 days after HD start); they were younger with a similar comorbidity profile (versus Hgb ≥10 g/dL). Month 1 Hgb was associated with first-year HD mortality (adjusted hazard ratio for 1 g/dL higher Hgb was 0.89; 95% confidence interval: 0.81-0.97), despite minimal differences in Month 4 Hgb. Patients with lower Hgb in Month 1 received higher doses of ESA, but not IV iron, over the first 3 months of HD. Results were consistent when excluding catheter users or adjusting for IV iron and ESA dose over the first 3 months. Even among patients with Hgb ≥10 g/dL 3 months later, anemia at HD initiation was common and associated with elevated mortality. A more proactive approach to anemia management in advanced chronic kidney disease (CKD) may thus improve survival on HD, though long-term prospective studies of non-dialysis CKD patients are needed.
Sections du résumé
BACKGROUND
BACKGROUND
Anemia at hemodialysis (HD) initiation is common. Correcting low hemoglobin (Hgb) before HD initiation may improve survival by avoiding potential harms of chronic anemia, high doses of erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron in the early HD period, and/or rapid Hgb rise.
METHODS
METHODS
We included 4604 incident HD patients from 21 countries in the Dialysis Outcomes and Practice Patterns Study Phases 4-5 (2009-15). Because low Hgb at HD start may reflect comorbidity or ESA hyporesponse, we restricted our analysis to the 80% of patients who achieved Hgb ≥10 g/dL 91-120 days after HD start (Month 4).
RESULTS
RESULTS
About 53% of these patients had Hgb <10 g/dL in Month 1 (<30 days after HD start); they were younger with a similar comorbidity profile (versus Hgb ≥10 g/dL). Month 1 Hgb was associated with first-year HD mortality (adjusted hazard ratio for 1 g/dL higher Hgb was 0.89; 95% confidence interval: 0.81-0.97), despite minimal differences in Month 4 Hgb. Patients with lower Hgb in Month 1 received higher doses of ESA, but not IV iron, over the first 3 months of HD. Results were consistent when excluding catheter users or adjusting for IV iron and ESA dose over the first 3 months.
CONCLUSIONS
CONCLUSIONS
Even among patients with Hgb ≥10 g/dL 3 months later, anemia at HD initiation was common and associated with elevated mortality. A more proactive approach to anemia management in advanced chronic kidney disease (CKD) may thus improve survival on HD, though long-term prospective studies of non-dialysis CKD patients are needed.
Identifiants
pubmed: 32699623
doi: 10.1093/ckj/sfz065
pii: sfz065
pmc: PMC7367115
doi:
Types de publication
Journal Article
Langues
eng
Pagination
425-433Informations de copyright
© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.
Références
Nephrol Dial Transplant. 2017 Jan 1;32(1):173-181
pubmed: 27604984
J Am Soc Nephrol. 2005 Oct;16(10):3070-80
pubmed: 16033854
Kidney Int. 2010 Jul;78(2):215-23
pubmed: 20428102
Curr Opin Nephrol Hypertens. 2017 May;26(3):214-218
pubmed: 28306566
J Am Soc Nephrol. 2015 Jun;26(6):1238-47
pubmed: 25542967
J Am Soc Nephrol. 2013 Jun;24(7):1151-8
pubmed: 23787911
Ther Apher Dial. 2010 Jun;14(3):240-75
pubmed: 20609178
N Engl J Med. 2009 Nov 19;361(21):2019-32
pubmed: 19880844
Am J Kidney Dis. 2013 Nov;62(5):849-59
pubmed: 23891356
Clin J Am Soc Nephrol. 2009 Mar;4(3):630-7
pubmed: 19261826
J Am Soc Nephrol. 2000 Mar;11(3):530-8
pubmed: 10703677
Kidney Int. 2015 Jan;87(1):162-8
pubmed: 25075769
Am J Kidney Dis. 2004 Nov;44(5):866-76
pubmed: 15492953
J Am Soc Nephrol. 2007 Mar;18(3):975-84
pubmed: 17267740
Am J Kidney Dis. 2004 Nov;44(5 Suppl 2):7-15
pubmed: 15486868
Kidney Int. 2011 Sep;80(6):663-9
pubmed: 21697811
N Engl J Med. 2006 Nov 16;355(20):2085-98
pubmed: 17108343
PLoS One. 2013 Nov 01;8(11):e78930
pubmed: 24223866
Nephrol Dial Transplant. 2013 Jun;28(6):1346-59
pubmed: 23585588
Adv Ther. 2013 Nov;30(11):1007-17
pubmed: 24173670
Clin Kidney J. 2017 Dec;10(Suppl 1):i16-i24
pubmed: 29225819
Nephrol Dial Transplant. 2008 Jan;23(1):301-8
pubmed: 17890745
J Am Soc Nephrol. 2004 Jun;15(6):1623-32
pubmed: 15153574
Kidney Int. 2016 Jan;89(1):28-39
pubmed: 26759045
N Engl J Med. 2019 Jan 31;380(5):447-458
pubmed: 30365356
Am J Kidney Dis. 2019 Mar;73(3):309-315
pubmed: 30578152
N Engl J Med. 1998 Aug 27;339(9):584-90
pubmed: 9718377
Lancet. 2007 Feb 3;369(9559):381-8
pubmed: 17276778
Nephrol Dial Transplant. 2015 Sep;30(9):1518-25
pubmed: 25829323
Hemodial Int. 2017 Jun;21 Suppl 1:S125-S131
pubmed: 28436206
Semin Dial. 2018 Jul;31(4):415-419
pubmed: 29509320
PLoS One. 2018 Sep 26;13(9):e0203767
pubmed: 30256836
Am J Kidney Dis. 2016 Nov;68(5):677-690
pubmed: 27321965
Clin J Am Soc Nephrol. 2014 Nov 7;9(11):1930-9
pubmed: 25318751
N Engl J Med. 1987 Jan 8;316(2):73-8
pubmed: 3537801
Clin J Am Soc Nephrol. 2010 Apr;5(4):553-6
pubmed: 20203166
Clin J Am Soc Nephrol. 2018 Mar 7;13(3):457-467
pubmed: 29463597
Nephrol Dial Transplant. 2015 Apr;30(4):667-75
pubmed: 25366328
N Engl J Med. 2006 Nov 16;355(20):2071-84
pubmed: 17108342
N Engl J Med. 2010 Jan 21;362(3):189-92
pubmed: 20054037
Cochrane Database Syst Rev. 2016 Jan 20;(1):CD003266
pubmed: 26790135
Pharmacoepidemiol Drug Saf. 2015 Oct;24(10):1068-75
pubmed: 26265483