在现患血液透析患者中，较高剂量的促红细胞生成素刺激剂和对其效果的低反应性与死亡率增加相关。
Higher doses of erythropoietin-stimulating agents and hyporesponsiveness to their effects are associated with increased mortality among prevalent hemodialysis patients.
机构信息
Division of Nephrology, University of Virginia Health System, Charlottesville, VA 22908, USA.
出版信息
Blood Purif. 2013;36(1):29-36. doi: 10.1159/000350583. Epub 2013 May 25.
BACKGROUND
Attempts to achieve near-normal hemoglobin levels have been associated with higher mortality among chronic kidney disease patients. Evidence suggests a higher mortality rate for those with resistance to erythropoietin-stimulating agents (ESA). We investigated the association between responsiveness to ESA, dose of ESA and mortality in our hemodialysis population.
METHODS
A retrospective cohort study of chronic hemodialysis patients receiving dialysis was conducted at the University of Virginia facilities. We collected data on patient demographics, comorbidities, dialysis vintage, vascular access type, body weight, ESA dose and hemoglobin, as well as data on known risk factors for ESA hyporesponsiveness. Vital status was determined 30 months later. The association between ESA responsiveness and mortality was investigated by using the Cox proportional hazard model adjusting for demographics, comorbidities, access type, dialysis adequacy, serum albumin, serum parathyroid hormone and ferritin concentrations.
RESULTS
A total of 606 patients were included. The overall 30-month mortality was 35.8%. Compared to those in the lowest tertile of ESA hyporesponsiveness, patients in the middle and upper tertiles had significantly higher mortality (hazard ratio, HR: 1.64, 95% CI: 1.14-2.37, and HR: 2.08, 95% CI: 1.46-2.97, respectively). In the Cox proportional hazard model each unit increment in the ESA resistance index was associated with an HR of 2.27 (95% CI: 1.60-3.23) for mortality. In this model each 1-unit increment in ESA dose/kg or each 100-μg increment in absolute darbepoetin alfa dose were associated with a 9% increased risk of mortality (HR: 1.09, 95% CI: 1.04-1.13, and HR: 1.09, 95% CI: 1.03-1.15, respectively).
CONCLUSIONS
Among prevalent hemodialysis patients, a higher degree of resistance to and higher doses of ESA are associated with increased mortality.
背景
试图使血红蛋白水平接近正常与慢性肾脏病患者的死亡率升高有关。有证据表明，对促红细胞生成素刺激剂（ESA）有抵抗的患者死亡率更高。我们研究了ESA 反应性、ESA 剂量与我们血液透析人群死亡率之间的关系。
方法
弗吉尼亚大学附属医院对接受透析的慢性血液透析患者进行了回顾性队列研究。我们收集了患者人口统计学、合并症、透析年限、血管通路类型、体重、ESA 剂量和血红蛋白的数据，以及已知 ESA 低反应性危险因素的数据。30 个月后确定患者的生存状态。使用 Cox 比例风险模型调整人口统计学、合并症、通路类型、透析充分性、血清白蛋白、血清甲状旁腺激素和铁蛋白浓度后，研究 ESA 反应性与死亡率之间的关系。
结果
共纳入 606 例患者。总体 30 个月死亡率为 35.8%。与 ESA 低反应性最低三分位组相比，中三分位和高三分位组患者死亡率显著升高（风险比，HR：1.64，95%置信区间：1.14-2.37，和 HR：2.08，95%置信区间：1.46-2.97）。在 Cox 比例风险模型中，ESA 抵抗指数每增加一个单位，死亡率的 HR 为 2.27（95%置信区间：1.60-3.23）。在该模型中，ESA 剂量/公斤增加 1 单位或绝对达贝泊汀 α 剂量增加 100μg，与死亡率增加 9%相关（HR：1.09，95%置信区间：1.04-1.13，和 HR：1.09，95%置信区间：1.03-1.15）。
结论
在现患血液透析患者中，对 ESA 的更高程度的抵抗和更高剂量与死亡率升高相关。
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