Keiichi Sumida1,2,3, Charles Dyer Diskin1, Miklos Z Molnar1,4, Praveen K Potukuchi1, Fridtjof Thomas5, Jun Ling Lu1, Connie M Rhee6, Elani Streja6, Kunihiro Yamagata3, Kamyar Kalantar-Zadeh6, Csaba P Kovesdy1,7. 1. Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA. 2. Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan. 3. Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan. 4. Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary. 5. Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA. 6. Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA. 7. Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA.
Abstract
BACKGROUND: Hemoglobin variability (Hb-var) has been associated with increased mortality both in non-dialysis dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD) patients. However, the impact of Hb-var in advanced NDD-CKD on outcomes after dialysis initiation remains unknown. METHODS: Among 11,872 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 through September 2011, we assessed Hb-var calculated from the residual SD of at least 3 Hb values during the last 6 months before dialysis initiation (prelude period) using within-subject linear regression models, and stratified into quartiles. Outcomes included post-transition all-cause, cardiovascular, and infection-related mortality, assessed in Cox proportional hazards models and adjusted for demographics, comorbidities, length of hospitalization, medications, estimated glomerular filtration rate (eGFR), type of vascular access, Hb parameters (baseline Hb [i.e., intercept] and change in Hb [i.e., slope]), and number of Hb measurements. RESULTS: Higher prelude Hb-var was associated with use of iron and antiplatelet agents, tunneled dialysis catheter use, higher levels of baseline Hb, change in Hb, eGFR, and serum ferritin. After multivariable adjustment, higher prelude Hb-var was associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality (adjusted hazard ratios [95% CI] for the highest [vs. lowest] quartile of Hb-var, 1.10 [1.02-1.19], 1.28 [0.93-1.75], and 0.93 [0.79-1.10], respectively). CONCLUSIONS: High pre-ESRD Hb-var is associated with higher mortality, particularly from infectious causes rather than cardiovascular causes. Further research is required to clarify the underlying mechanisms and true causal nature of the observed association.
BACKGROUND: Hemoglobin variability (Hb-var) has been associated with increased mortality both in non-dialysis dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD) patients. However, the impact of Hb-var in advanced NDD-CKD on outcomes after dialysis initiation remains unknown. METHODS: Among 11,872 US veterans with advanced NDD-CKD transitioning to dialysis between October 2007 through September 2011, we assessed Hb-var calculated from the residual SD of at least 3 Hb values during the last 6 months before dialysis initiation (prelude period) using within-subject linear regression models, and stratified into quartiles. Outcomes included post-transition all-cause, cardiovascular, and infection-related mortality, assessed in Cox proportional hazards models and adjusted for demographics, comorbidities, length of hospitalization, medications, estimated glomerular filtration rate (eGFR), type of vascular access, Hb parameters (baseline Hb [i.e., intercept] and change in Hb [i.e., slope]), and number of Hb measurements. RESULTS: Higher prelude Hb-var was associated with use of iron and antiplatelet agents, tunneled dialysis catheter use, higher levels of baseline Hb, change in Hb, eGFR, and serum ferritin. After multivariable adjustment, higher prelude Hb-var was associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality (adjusted hazard ratios [95% CI] for the highest [vs. lowest] quartile of Hb-var, 1.10 [1.02-1.19], 1.28 [0.93-1.75], and 0.93 [0.79-1.10], respectively). CONCLUSIONS: High pre-ESRD Hb-var is associated with higher mortality, particularly from infectious causes rather than cardiovascular causes. Further research is required to clarify the underlying mechanisms and true causal nature of the observed association.
Authors: Csaba P Kovesdy; Ahmed Alrifai; Elvira O Gosmanova; Jun Ling Lu; Robert B Canada; Barry M Wall; Adriana M Hung; Miklos Z Molnar; Kamyar Kalantar-Zadeh Journal: Clin J Am Soc Nephrol Date: 2016-04-21 Impact factor: 8.237
Authors: Rajiv Saran; Yi Li; Bruce Robinson; Kevin C Abbott; Lawrence Y C Agodoa; John Ayanian; Jennifer Bragg-Gresham; Rajesh Balkrishnan; Joline L T Chen; Elizabeth Cope; Paul W Eggers; Daniel Gillen; Debbie Gipson; Susan M Hailpern; Yoshio N Hall; Kevin He; William Herman; Michael Heung; Richard A Hirth; David Hutton; Steven J Jacobsen; Kamyar Kalantar-Zadeh; Csaba P Kovesdy; Yee Lu; Miklos Z Molnar; Hal Morgenstern; Brahmajee Nallamothu; Danh V Nguyen; Ann M O'Hare; Brett Plattner; Ronald Pisoni; Friedrich K Port; Panduranga Rao; Connie M Rhee; Ankit Sakhuja; Douglas E Schaubel; David T Selewski; Vahakn Shahinian; John J Sim; Peter Song; Elani Streja; Manjula Kurella Tamura; Francesca Tentori; Sarah White; Kenneth Woodside; Richard A Hirth Journal: Am J Kidney Dis Date: 2016-03 Impact factor: 8.860
Authors: Marc A Pfeffer; Emmanuel A Burdmann; Chao-Yin Chen; Mark E Cooper; Dick de Zeeuw; Kai-Uwe Eckardt; Jan M Feyzi; Peter Ivanovich; Reshma Kewalramani; Andrew S Levey; Eldrin F Lewis; Janet B McGill; John J V McMurray; Patrick Parfrey; Hans-Henrik Parving; Giuseppe Remuzzi; Ajay K Singh; Scott D Solomon; Robert Toto Journal: N Engl J Med Date: 2009-10-30 Impact factor: 91.245
Authors: Andrew S Levey; Lesley A Stevens; Christopher H Schmid; Yaping Lucy Zhang; Alejandro F Castro; Harold I Feldman; John W Kusek; Paul Eggers; Frederick Van Lente; Tom Greene; Josef Coresh Journal: Ann Intern Med Date: 2009-05-05 Impact factor: 25.391