Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.
JAMA. 2010 Mar 3;303(9):857-64. doi: 10.1001/jama.2010.206.
Controversy exists about optimal management of anemia in end-stage renal disease.
To compare the mortality risk of different dialysis center-level patterns of anemia management.
DESIGN, SETTING, AND PATIENTS: Using data from Medicare's end-stage renal disease program (1999-2007), we characterized each US dialysis center's annual anemia management practice by estimating its typical use of erythropoiesis-stimulating agents (ESAs) and intravenous iron in hemodialysis patients within 4 hematocrit categories. We used Cox proportional hazards regression to correlate center-level patterns of ESA and iron use with 1-year mortality risk in 269,717 incident hemodialysis patients.
One-year all-cause mortality.
Monthly mortality rates were highest in patients with hematocrit less than 30% (mortality, 2.1%) and lowest for those with hematocrit of 36% or higher (mortality, 0.7%). After adjustment for baseline case-mix differences, dialysis centers that used larger ESA doses in patients with hematocrit less than 30% had lower mortality rates than centers that used smaller doses (highest vs lowest dose group: hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.90-0.97). Centers that administered iron more frequently to patients with hematocrit less than 33% also had lower mortality rates (highest vs lowest quintile, HR, 0.95; 95% CI, 0.91-0.98). However, centers that used larger ESA doses in patients with hematocrit between 33% and 35.9% had higher mortality rates (highest vs lowest quintile, HR, 1.07; 95% CI, 1.03-1.12). More intensive use of both ESAs and iron was associated with increased mortality risk in patients with hematocrit of 36% or higher. These findings persisted across a range of secondary analyses.
Greater ESA and iron use were associated with decreased mortality risk at lower hematocrit levels, in which mortality rates are the highest. Although the overall mortality rate was lower at higher hematocrit levels, elevated mortality risk was associated with greater use of ESAs and iron in these patients.
关于终末期肾病患者贫血的最佳治疗方法，存在争议。
比较不同透析中心贫血管理模式的死亡率风险。
设计、地点和患者：利用美国医疗保险的终末期肾脏病项目（1999-2007 年）的数据，我们通过估计每个美国透析中心在 4 个红细胞比容类别内的血液透析患者典型的促红细胞生成素（ESA）和静脉铁的使用情况，来描述每个透析中心的年度贫血管理实践。我们使用 Cox 比例风险回归分析，将中心水平的 ESA 和铁的使用与 269717 例新发生血液透析患者的 1 年死亡率风险相关联。
1 年全因死亡率。
红细胞比容小于 30%的患者每月死亡率最高（死亡率 2.1%），红细胞比容为 36%或更高的患者死亡率最低（死亡率 0.7%）。在调整基线病例组合差异后，红细胞比容小于 30%的患者中使用较大 ESA 剂量的透析中心死亡率低于使用较小剂量的中心（最高剂量组与最低剂量组相比：风险比[HR]，0.94；95%置信区间[CI]，0.90-0.97）。对于红细胞比容小于 33%的患者，更频繁地给予铁的中心死亡率也较低（最高与最低五分位数相比，HR，0.95；95%CI，0.91-0.98）。然而，红细胞比容在 33%-35.9%之间的患者中使用较大 ESA 剂量的中心死亡率较高（最高与最低五分位数相比，HR，1.07；95%CI，1.03-1.12）。对于红细胞比容为 36%或更高的患者，更积极地使用 ESA 和铁与死亡率风险增加相关。这些发现贯穿了一系列次要分析。
在较低的红细胞比容水平，即死亡率最高的水平，ESA 和铁的使用量增加与死亡率降低相关。虽然在较高的红细胞比容水平总体死亡率较低，但这些患者中 ESA 和铁的使用量增加与死亡率风险升高相关。
