Gilbertson David T, Hu Yan, Peng Yi, Maroni Bradley J, Wetmore James B
Clin Nephrol. 2017 Nov;88(11):254-265. doi: 10.5414/CN109031.
Given regulatory and reimbursement changes in anemia management, we examined hemoglobin variability in a contemporary cohort of maintenance hemodialysis patients.
The study population included > 200,000 hemodialysis patients with Medicare parts A and B as primary payer on October 1, 2012. Based on 25th and 75th percentiles, monthly hemoglobin values were categorized as low, intermediate, or high. Six variability categories were created by patterns during the 6-month observation period. Stable categories were: always-low, alwaysintermediate, always-high; variable patterns were: varying between low and intermediate, intermediate and high, low and high (mostvariable). Cox proportional hazard models were used to assess the association between hemoglobin variability and all-cause mortality or major adverse cardiac events (MACE).
The 25 and 75 hemoglobin percentiles were 10.2 and 11.5 g/dL, respectively, in 2012, vs. 11 and 12.5 g/dL in 2004. ESA doses were lower in all categories in 2012 and transfusion rates higher, particularly for always-low patients. Hemoglobin variability decreased modestly: in 2004, 6.0% were always-intermediate, vs. 9.5% in 2012. In 2012, more patients were always-high and fewer were most-variable. Mortality hazard ratios (HRs) were higher for patients with any low hemoglobin: always-low (HR, 95% CI: 2.07, 1.84 - 2.31), varying between low and intermediate (1.37, 1.29 - 1.45), and most-variable (1.23, 1.16 - 1.31); the pattern was similar for MACE.
In 2012 vs. 2004, hemoglobin levels decreased, the range of levels narrowed, and variability decreased modestly; transfusions increased. The highest risk of mortality and MACE appeared to occur in patients with persistently low, rather than highly variable, hemoglobin levels.
鉴于贫血管理方面的监管和报销政策变化，我们对当代维持性血液透析患者队列中的血红蛋白变异性进行了研究。
研究人群包括2012年10月1日以医疗保险A部分和B部分作为主要支付方的超过200,000名血液透析患者。根据第25和第75百分位数，将每月血红蛋白值分为低、中、高三类。通过6个月观察期内的模式创建了六个变异性类别。稳定类别为：始终低、始终中、始终高；可变模式为：在低和中之间变化、在中和高之间变化、在低和高之间变化（变异性最大）。使用Cox比例风险模型评估血红蛋白变异性与全因死亡率或主要不良心脏事件（MACE）之间的关联。
2012年血红蛋白的第25和第75百分位数分别为10.2和11.5 g/dL，而2004年为11和12.5 g/dL。2012年所有类别中的促红细胞生成素（ESA）剂量均较低，输血率较高，尤其是始终低血红蛋白水平的患者。血红蛋白变异性略有下降：2004年，6.0%为始终中，2012年为9.5%。2012年，始终高血红蛋白水平的患者更多，变异性最大的患者更少。任何低血红蛋白水平患者的死亡风险比（HR）更高：始终低（HR，95%置信区间：2.07，1.84 - 2.31），在低和中之间变化（1.37，1.29 - 1.45），以及变异性最大（1.23，1.16 - 1.31）；MACE的模式相似。
与2004年相比，2012年血红蛋白水平下降，水平范围变窄，变异性略有下降；输血增加。死亡率和MACE的最高风险似乎发生在血红蛋白水平持续较低而非变异性高的患者中。
