Pisoni Ronald L, Bragg-Gresham Jennifer L, Young Eric W, Akizawa Tadao, Asano Yasushi, Locatelli Francesco, Bommer Juergen, Cruz Jose Miguel, Kerr Peter G, Mendelssohn David C, Held Philip J, Port Friedrich K
University Renal Research and Education Association, Ann Arbor, MI, USA.
Am J Kidney Dis. 2004 Jul;44(1):94-111. doi: 10.1053/j.ajkd.2004.03.023.
Anemia is common in hemodialysis (HD) patients.
Data collected from nationally representative samples of HD patients (n = 11,041) in 2002 to 2003 were used to describe current anemia management for long-term HD patients at 309 dialysis units in 12 countries. Analyses of associations and outcomes were adjusted for demographics, 15 comorbid classes, laboratory values, country, and facility clustering.
For patients on dialysis therapy for longer than 180 days, 23% to 77% had a hemoglobin (Hgb) concentration less than 11 g/dL (<110 g/L), depending on country; 83% to 94% were administered erythropoietin (EPO). Mean Hgb levels were 12 g/dL (120 g/L) in Sweden; 11.6 to 11.7 g/dL (116 to 117 g/L) in the United States, Spain, Belgium, and Canada; 11.1 to 11.5 g/dL (111 to 115 g/L) in Australia/New Zealand, Germany, Italy, the United Kingdom, and France; and 10.1 g/dL (101 g/L) in Japan. Hgb levels were substantially lower for new patients with end-stage renal disease, and EPO use before ESRD ranged from 27% (United States) to 65% (Sweden). By patient, EPO use significantly declined with greater Hgb concentration (adjusted odds ratio, 0.61 per 1-g/dL [10-g/L] greater Hgb level; P < 0.0001), as did EPO dosage. Case-mix-adjusted mortality and hospitalization risk declined by 5% and 6% per 1-g/dL greater patient baseline Hgb level (P < or = 0.003 each), respectively. Furthermore, patient mortality and hospitalization risks were 10% to 12% lower for every 1-g/dL greater facility mean Hgb level. Patients were significantly more likely to have Hgb levels of 11 g/dL or greater (> or =110 g/L) if they were older; were men; had polycystic kidney disease; had greater albumin, transferrin saturation, or calcium levels; were not dialyzing with a catheter; or had lower ferritin levels. Facilities with greater intravenous iron use showed significantly greater facility mean Hgb concentrations. Mean EPO dose varied from 5,297 (Japan) to 17,360 U/wk (United States). Greater country mean EPO doses were significantly associated with greater country mean Hgb concentrations. Several patient characteristics were associated with greater EPO doses. Even in some countries with high intravenous iron use, 35% to 40% of patients had a transferrin saturation less than 20% (below guidelines).
These findings indicate large international variations in anemia management, with significant improvements during the last 5 years, although many patients remain below current anemia guidelines, suggesting large and specific opportunities for improvement.
贫血在血液透析（HD）患者中很常见。
收集2002年至2003年来自12个国家309个透析单位具有全国代表性的HD患者样本（n = 11,041）的数据，以描述12个国家长期HD患者目前的贫血管理情况。对关联和结果的分析针对人口统计学、15种合并症类别、实验室值、国家和机构聚类进行了调整。
对于接受透析治疗超过180天的患者，根据国家不同，23%至77%的患者血红蛋白（Hgb）浓度低于11 g/dL（<110 g/L）；83%至94%的患者接受了促红细胞生成素（EPO）治疗。瑞典患者的平均Hgb水平为12 g/dL（120 g/L）；美国、西班牙、比利时和加拿大为11.6至11.7 g/dL（116至117 g/L）；澳大利亚/新西兰、德国、意大利、英国和法国为11.1至11.5 g/dL（111至115 g/L）；日本为10.1 g/dL（101 g/L）。终末期肾病新患者的Hgb水平显著更低，并且ESRD前EPO的使用率从27%（美国）到65%（瑞典）不等。按患者来看，随着Hgb浓度升高，EPO的使用显著下降（校正比值比，Hgb水平每升高1 g/dL [10 g/L]为0.61；P < 0.0001），EPO剂量也是如此。病例组合调整后的死亡率和住院风险分别随着患者基线Hgb水平每升高1 g/dL而降低5%和6%（P均≤0.003）。此外，机构平均Hgb水平每升高1 g/dL，患者的死亡率和住院风险会降低10%至12%。如果患者年龄较大、为男性、患有多囊肾病、白蛋白、转铁蛋白饱和度或钙水平较高、不是通过导管进行透析或者铁蛋白水平较低，则其Hgb水平≥11 g/dL（≥110 g/L）的可能性显著更高。静脉铁使用量较高的机构显示出显著更高的机构平均Hgb浓度。平均EPO剂量从5,297（日本）到17,360 U/周（美国）不等。国家平均EPO剂量较高与国家平均Hgb浓度较高显著相关。一些患者特征与较高的EPO剂量相关。即使在一些静脉铁使用量较高的国家，35%至40%的患者转铁蛋白饱和度低于20%（低于指南）。
这些发现表明贫血管理在国际上存在很大差异，尽管许多患者仍低于当前贫血指南，但在过去5年中有显著改善，这表明存在巨大且具体的改进机会。
