Gilbertson David T, Ebben James P, Foley Robert N, Weinhandl Eric D, Bradbury Brian D, Collins Allan J
Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 South 8th Street, Suite S-206, Minneapolis, MN 55404, USA.
Clin J Am Soc Nephrol. 2008 Jan;3(1):133-8. doi: 10.2215/CJN.01610407. Epub 2007 Nov 28.
BACKGROUND/OBJECTIVES: Awareness of hemoglobin level variability in dialysis patients is increasing, as is interest in its potential implications. In this retrospective, national study of associations between the degree of hemoglobin level variability in the first 6 mo of 2004 and subsequent mortality rates in the following 6 mo, 159,720 hemodialysis patients receiving epoetin therapy were studied.
DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: Monthly hemoglobin values were categorized as low (L; < 11 g/dl), intermediate (I; 11 to 12.5 g/dl), and high (H; >12.5 g/dl). Variability groups were classified on the basis of the lowest and highest hemoglobin categories seen during the 6-mo observation period: low-low (L-L), 1.4%; intermediate-intermediate (I-I), 6.0%; high-high (H-H), 2.3%; low-intermediate (L-I), 18.3%; intermediate-high (I-H), 31.7%, and low-high (L-H), 40.2%.
On multivariate analysis, adjusted hazards ratios for subsequent mortality events were as follows: I-I, 1.0 (reference category); I-H, 1.02 (95% confidence interval [CI] 0.95 to 1.11); H-H, 1.06 (95% CI 0.93 to 1.21); L-H, 1.19 (95% CI 1.10 to 1.28); L-I, 1.44 (95% CI 1.33 to 1.56), and L-L, 2.18 (95% CI 1.93 to 2.45). Persistently and transiently low hemoglobin levels and highly variable hemoglobin levels were associated with increased risk of death; transiently and persistently high hemoglobin levels were not associated with increased risk of death. Bayesian modeling indicated that > or =3 mo with hemoglobin levels <11 g/dl may be associated with of increased risk of death.
Number of months with hemoglobin values below the target range, rather than hemoglobin variability itself, may be the primary driver of increased risk of death. Further research is needed to distinguish cause from effect and to understand the underlying mechanisms.
背景/目的：透析患者对血红蛋白水平变异性的认识正在提高，对其潜在影响的兴趣也在增加。在这项关于2004年最初6个月血红蛋白水平变异性程度与随后6个月死亡率之间关联的全国性回顾性研究中，对159,720名接受促红细胞生成素治疗的血液透析患者进行了研究。
设计、设置、参与者、测量：每月血红蛋白值分为低（L；<11 g/dl）、中（I；11至12.5 g/dl）和高（H；>12.5 g/dl）。变异性组根据6个月观察期内所见的最低和最高血红蛋白类别进行分类：低-低（L-L），1.4%；中-中（I-I），6.0%；高-高（H-H），2.3%；低-中（L-I），18.3%；中-高（I-H），31.7%，以及低-高（L-H），40.2%。
在多变量分析中，随后死亡事件的调整风险比如下：I-I，1.0（参考类别）；I-H，1.02（95%置信区间[CI]0.95至1.11）；H-H，1.06（95%CI 0.93至1.21）；L-H，1.19（95%CI 1.10至1.28）；L-I，1.44（95%CI 1.33至1.56），以及L-L，2.18（95%CI 1.93至2.45）。持续和短暂的低血红蛋白水平以及高度可变的血红蛋白水平与死亡风险增加相关；短暂和持续的高血红蛋白水平与死亡风险增加无关。贝叶斯模型表明，血红蛋白水平<11 g/dl持续≥3个月可能与死亡风险增加相关。
血红蛋白值低于目标范围的月数，而非血红蛋白变异性本身，可能是死亡风险增加的主要驱动因素。需要进一步研究以区分因果关系并了解潜在机制。
