Go Alan S, Yang Jingrong, Ackerson Lynn M, Lepper Krista, Robbins Sean, Massie Barry M, Shlipak Michael G
Division of Research, Kaiser Permanente of Northern California, 2000 Broadway St, 3rd Floor, Oakland, California 94612-2304, USA.
Circulation. 2006 Jun 13;113(23):2713-23. doi: 10.1161/CIRCULATIONAHA.105.577577. Epub 2006 Jun 5.
Previous studies have associated reduced hemoglobin levels with increased adverse events in heart failure. It is unclear, however, whether this relation is explained by underlying kidney disease, treatment differences, or associated comorbidity.
We examined the associations between hemoglobin level, kidney function, and risks of death and hospitalization in persons with chronic heart failure between 1996 and 2002 within a large, integrated, healthcare delivery system in northern California. Longitudinal outpatient hemoglobin and creatinine levels and clinical and treatment characteristics were obtained from health plan records. Glomerular filtration rate (GFR; mL.min(-1).1.73 m(-2)) was estimated from the Modification of Diet in Renal Disease equation. Mortality data were obtained from state death files; heart failure admissions were identified by primary discharge diagnoses. Among 59,772 adults with heart failure, the mean age was 72 years and 46% were women. Compared with that for hemoglobin levels of 13.0 to 13.9 g/dL, the multivariable-adjusted risk of death increased with lower hemoglobin levels: an adjusted hazard ratio (HR) of 1.16 and 95% confidence interval (CI) of 1.11 to 1.21 for hemoglobin levels of 12.0 to 12.9 g/dL; HR, 1.50 and 95% CI, 1.44 to 1.57 for 11.0 to 11.9 g/dL; HR, 1.89 and 95% CI, 1.80 to 1.98 for 10.0 to 10.9; HR, 2.31 and 95% CI, 2.18 to 2.45 for 9.0 to 9.9; and HR, 3.48 and 95% CI, 3.25 to 3.73 for <9.0 g/dL. Hemoglobin levels > or = 17.0 g/dL were associated with an increased risk of death (adjusted HR, 1.42; 95% CI, 1.24 to 1.63). Compared with those with a GFR > or = 60 mL . min(-1).1.73 m(-2), persons with a GFR <45 mL.min(-1).1.73 m(-2) had an increased mortality risk: adjusted HR, 1.39 and 95% CI, 1.34 to 1.44 for 30 to 44; HR, 2.28 and 95% CI, 2.19 to 2.39 for 15 to 29; HR, 3.26 and 95% CI, 3.05 to 3.49 for <15; and HR, 2.44 and 95% CI, 2.28 to 2.61 for those on dialysis. Relations were similar for the risk of hospitalization. The findings did not differ among patients with preserved or reduced systolic function, and hemoglobin level was an independent predictor of outcomes at all levels of kidney function.
Very high (> or = 17 g/dL) or reduced (<13 g/dL) hemoglobin levels and chronic kidney disease independently predict substantially increased risks of death and hospitalization in heart failure, regardless of the level of systolic function. Randomized trials are needed to evaluate whether raising hemoglobin levels can improve outcomes in chronic heart failure.
既往研究表明，心力衰竭患者血红蛋白水平降低与不良事件增加相关。然而，尚不清楚这种关系是由潜在的肾脏疾病、治疗差异还是合并症所导致。
我们在加利福尼亚北部一个大型综合医疗服务系统中，研究了1996年至2002年期间慢性心力衰竭患者的血红蛋白水平、肾功能与死亡及住院风险之间的关联。从健康计划记录中获取纵向门诊血红蛋白和肌酐水平以及临床和治疗特征。根据肾脏病饮食改良方程估算肾小球滤过率（GFR；mL·min⁻¹·1.73 m⁻²）。死亡数据来自州死亡档案；通过主要出院诊断确定心力衰竭住院情况。在59772例心力衰竭成人患者中，平均年龄为72岁，46%为女性。与血红蛋白水平为13.0至13.9 g/dL的患者相比，血红蛋白水平越低，多变量调整后的死亡风险越高：血红蛋白水平为12.0至12.9 g/dL时，调整后的风险比（HR）为1.16，95%置信区间（CI）为1.11至1.21；11.0至11.9 g/dL时，HR为1.50，95% CI为1.44至1.57；10.0至10.9时，HR为1.89，95% CI为1.80至1.98；9.0至9.9时，HR为2.31，95% CI为2.18至2.45；<9.0 g/dL时，HR为3.48，95% CI为3.25至3.73。血红蛋白水平≥17.0 g/dL与死亡风险增加相关（调整后的HR为1.42；95% CI为1.24至1.63）。与GFR≥60 mL·min⁻¹·1.73 m⁻²的患者相比，GFR<45 mL·min⁻¹·1.73 m⁻²的患者死亡风险增加：30至44时，调整后的HR为1.39，95% CI为1.34至1.44；15至29时，HR为2.28，95% CI为2.19至2.39；<15时，HR为3.26，95% CI为3.05至3.49；接受透析的患者HR为2.44，95% CI为2.28至2.61。住院风险的关系相似。收缩功能保留或降低的患者结果无差异，血红蛋白水平是所有肾功能水平下结局的独立预测因素。
极高（≥17 g/dL）或降低（<13 g/dL）的血红蛋白水平以及慢性肾脏疾病独立预测心力衰竭患者死亡和住院风险大幅增加，无论收缩功能水平如何。需要进行随机试验来评估提高血红蛋白水平是否能改善慢性心力衰竭的结局。
