Young Eric W, Wang Dongyu, Kapke Alissa, Pearson Jeffrey, Turenne Marc, Robinson Bruce M, Huff Edwin D
Arbor Research Collaborative for Health, Ann Arbor, MI.
Centers for Medicare & Medicaid Services, Baltimore, MD.
Kidney Med. 2022 Dec 7;5(2):100578. doi: 10.1016/j.xkme.2022.100578. eCollection 2023 Feb.
RATIONALE & OBJECTIVE: Anemia management in patients treated with maintenance dialysis remains a challenge. We sought to update information in this area by evaluating the association between hemoglobin and various outcome and utilization measures using data-rich Medicare sources.
Observational cohort study using data from the Consolidated Renal Operations in a Web-enabled Network and Medicare claims.
SETTING & PARTICIPANTS: We studied 371,250 prevalent patients treated with hemodialysis, covering 3,326,072 patient-months in 2019.
Monthly patient hemoglobin concentrations.
We examined several outcomes, including mortality, all-cause hospitalization, cause-specific hospitalization, and emergency department utilization in the month following the exposure measurement.
For each monthly observation period, we calculated unadjusted and adjusted (for demographics and comorbid condition) hazard ratios using Cox regression.
The hemoglobin concentration was <10.5 g/dL for 40% of observations. We found an inverse association between mortality and hemoglobin measured over a range from <9 g/dL (HR, 2.53; 95% CI, 2.45-2.61; < 0.0001, reference = 10.5-11 g/dL) to 11-11.5 g/dL (HR, 0.92; 95% CI, 0.89-0.96; < 0.0001). Mortality risk started to increase at hemoglobin levels >11.5 g/dL. All-cause hospitalization, cause-specific hospitalization (including cardiovascular, infection, and several subcategories including coronavirus disease 2019 hospitalization), and emergency department utilization were inversely associated with hemoglobin concentration, with risk reduction stabilizing at hemoglobin levels of approximately 11.5-12 g/dL and higher.
As with prior observational studies, the observed associations are not necessarily causal.
In a large US hemodialysis population, there were better clinical outcomes at higher hemoglobin concentrations over short exposure and follow-up periods, consistent with other observational studies that generally used longer exposure and follow-up times. Mortality risk increased at hemoglobin concentrations >11.5 g/dL, consistent with findings from erythropoiesis-stimulating agent clinical trials. The apparently beneficial short-term effects associated with higher hemoglobin concentrations suggest that hemoglobin measurements capture unmeasured elements of patient risk.
维持性透析患者的贫血管理仍然是一项挑战。我们试图通过使用数据丰富的医疗保险数据源评估血红蛋白与各种结局及利用指标之间的关联，来更新该领域的信息。
使用来自基于网络的综合肾脏手术和医疗保险索赔数据的观察性队列研究。
我们研究了371,250例接受血液透析的现患患者，涵盖2019年的3,326,072个患者月。
每月患者血红蛋白浓度。
我们检查了多个结局指标，包括死亡率、全因住院率、特定病因住院率以及暴露测量后一个月内的急诊科就诊率。
对于每个月度观察期，我们使用Cox回归计算未调整和调整（针对人口统计学和合并症）的风险比。
40%的观察结果显示血红蛋白浓度<10.5 g/dL。我们发现，在血红蛋白浓度范围从<9 g/dL（风险比，2.53；95%置信区间，2.45 - 2.61；P<0.0001，参照=10.5 - 11 g/dL）到11 - 11.5 g/dL（风险比，0.92；95%置信区间，0.89 - 0.96；P<0.0001）之间，死亡率与血红蛋白呈负相关。血红蛋白水平>11.5 g/dL时，死亡风险开始增加。全因住院率、特定病因住院率（包括心血管、感染以及几个子类别，包括2019冠状病毒病住院）和急诊科就诊率与血红蛋白浓度呈负相关，风险降低在血红蛋白水平约为11.5 - 12 g/dL及更高时趋于稳定。
与先前的观察性研究一样，观察到的关联不一定是因果关系。
在美国大量血液透析人群中，在较短的暴露和随访期内，较高的血红蛋白浓度与更好的临床结局相关，这与其他通常使用更长暴露和随访时间的观察性研究一致。血红蛋白浓度>11.5 g/dL时死亡风险增加，这与促红细胞生成素刺激剂临床试验的结果一致。与较高血红蛋白浓度相关的明显短期有益效应表明，血红蛋白测量反映了未测量的患者风险因素。
