Collins Allan J, Li Suying, Peter Wendy St, Ebben Jim, Roberts Tricia, Ma Jennie Z, Manning Willard
Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota.
Nephrology Analytical Services, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
J Am Soc Nephrol. 2001 Nov;12(11):2465-2473. doi: 10.1681/ASN.V12112465.
Anemia treatment with epoetin has led to dramatic increases in hematocrit levels since 1989. Studies have demonstrated that morbidity and mortality rates are lower when hematocrit values are within the Disease Outcomes Quality Initiative (DOQI) target range (33 to 36%). Recently, clinical studies demonstrated that patients without cardiovascular disease exhibited lower morbidity rates and improved cognitive function with hematocrit values of >36%. One prospective trial, in contrast, demonstrated that normal hematocrit values among patients with cardiac disease were associated with higher mortality rates. These conflicting results have led to concerns regarding the risks and benefits associated with hematocrit values between 36 and 42%. To address these concerns, a recent cohort of 1996 to 1998 incident hemodialysis patients was studied, with assessments of the risks of death and hospitalization and the medical costs associated with hematocrit values of >36%. Patients survived at least 9 mo after dialysis initiation, and comorbidity, disease severity, and hematocrit levels were determined for months 4 to 9. Patients were grouped on the basis of hematocrit values, i.e., <30, 30 to <33, 33 to <36, 36 to <39, or > or =39%, with 1 yr of follow-up monitoring. A Cox regression model was used to evaluate all-cause and cause-specific mortality and hospitalization rates. The economic evaluations included analyses with Medicare Parts A and B allowable expenditures as the dependent variable and the same clinical characteristics as independent variables. For patients with hematocrit values of > or =36%, mortality rates were not different, hospitalization rates were 16 to 22% lower, and expenditures were 8.3 to 8.5% less, compared with patients with hematocrit values of 33 to <36%. These observations do not demonstrate causality. Additional long-term studies are needed to assess the risks of higher hematocrit values among all patients and patients with cardiovascular disease.
自1989年以来，使用促红细胞生成素治疗贫血已使血细胞比容水平显著提高。研究表明，当血细胞比容值处于疾病转归质量倡议（DOQI）目标范围（33%至36%）内时，发病率和死亡率较低。最近，临床研究表明，无心血管疾病的患者血细胞比容值>36%时发病率较低且认知功能得到改善。相比之下，一项前瞻性试验表明，心脏病患者的正常血细胞比容值与较高的死亡率相关。这些相互矛盾的结果引发了对血细胞比容值在36%至42%之间相关风险和益处的担忧。为解决这些担忧，对1996年至1998年期间新发生的血液透析患者进行了一项队列研究，评估了死亡和住院风险以及血细胞比容值>36%相关的医疗费用。患者在开始透析后至少存活9个月，并在第4至9个月确定合并症、疾病严重程度和血细胞比容水平。根据血细胞比容值将患者分组，即<30%、30%至<33%、33%至<36%、36%至<39%或≥39%，并进行1年的随访监测。使用Cox回归模型评估全因死亡率和特定病因死亡率以及住院率。经济评估包括以医疗保险A部分和B部分允许支出作为因变量、相同临床特征作为自变量的分析。与血细胞比容值为33%至<36%的患者相比，血细胞比容值≥36%的患者死亡率无差异，住院率低16%至22%，支出少8.3%至8.5%。这些观察结果并未证明因果关系。需要更多长期研究来评估所有患者以及心血管疾病患者血细胞比容值较高的风险。
