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Le Gall L, Harambat J, Combe C, Philipps V, Proust-Lima C, Dussartre M, Drüeke T, Choukroun G, Fouque D, Frimat L, Jacquelinet C, Laville M, Liabeuf S, Pecoits-Filho R, Massy ZA, Stengel B, Alencar de Pinho N, Leffondré K, Prezelin-Reydit M. Haemoglobin trajectories in chronic kidney disease and risk of major adverse cardiovascular events. Nephrol Dial Transplant 2024; 39:669-682. [PMID: 37935529 DOI: 10.1093/ndt/gfad235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND The trajectories of haemoglobin in patients with chronic kidney disease (CKD) have been poorly described. In such patients, we aimed to identify typical haemoglobin trajectory profiles and estimate their risks of major adverse cardiovascular events (MACE). METHODS We used 5-year longitudinal data from the CKD-REIN cohort patients with moderate to severe CKD enrolled from 40 nationally representative nephrology clinics in France. A joint latent class model was used to estimate, in different classes of haemoglobin trajectory, the competing risks of (i) MACE + defined as the first event among cardiovascular death, non-fatal myocardial infarction, stroke or hospitalization for acute heart failure, (ii) initiation of kidney replacement therapy (KRT) and (iii) non-cardiovascular death. RESULTS During the follow-up, we gathered 33 874 haemoglobin measurements from 3011 subjects (median, 10 per patient). We identified five distinct haemoglobin trajectory profiles. The predominant profile (n = 1885, 62.6%) showed an overall stable trajectory and low risks of events. The four other profiles had nonlinear declining trajectories: early strong decline (n = 257, 8.5%), late strong decline (n = 75, 2.5%), early moderate decline (n = 356, 11.8%) and late moderate decline (n = 438, 14.6%). The four profiles had different risks of MACE, while the risks of KRT and non-cardiovascular death consistently increased from the haemoglobin decline. CONCLUSION In this study, we observed that two-thirds of patients had a stable haemoglobin trajectory and low risks of adverse events. The other third had a nonlinear trajectory declining at different rates, with increased risks of events. Better attention should be paid to dynamic changes of haemoglobin in CKD.
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Affiliation(s)
- Lisa Le Gall
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
- University Bordeaux, INSERM, CIC-1401-EC, Bordeaux, France
| | - Jérôme Harambat
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
- University Bordeaux, INSERM, CIC-1401-EC, Bordeaux, France
- Bordeaux University Hospital, Pediatric Nephrology Unit, Centre de Référence des Maladies Rénales Rares Sorare, Pellegrin-Enfants Hospital, Bordeaux, France
| | - Christian Combe
- Bordeaux University Hospital, Department of Nephrology, transplantation, dialysis, Bordeaux, France
- University Bordeaux, INSERM U1026, Bordeaux, France
| | - Viviane Philipps
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
| | - Cécile Proust-Lima
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
| | - Maris Dussartre
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
| | - Tilman Drüeke
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint-Quentin University, Inserm U1018 Clinical Epidemiology Team, Villejuif, France
| | - Gabriel Choukroun
- Amiens Picardie University Hospital, Department of Nephrology Dialysis Transplantation, Amiens, France
- University of Picardie Jules Verne, MP3CV Research Unit, Amiens, France
| | - Denis Fouque
- Hopital Lyon Sud, Département de néphrologie, Lyon, France
- Université Claude Bernard Lyon 1, Carmen INSERM U1060, Pierre-Bénite, France
| | - Luc Frimat
- CHRU de Nancy, Department of Nephrology, Vandoeuvre-lès-Nancy, France
- Lorraine University, APEMAC, Nancy, France
| | - Christian Jacquelinet
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint-Quentin University, Inserm U1018 Clinical Epidemiology Team, Villejuif, France
- Agence de la biomedecine, La Plaine-Saint-Denis, France
| | - Maurice Laville
- Université Claude Bernard Lyon 1, Carmen INSERM U1060, Pierre-Bénite, France
| | - Sophie Liabeuf
- University of Picardie Jules Verne, MP3CV Research Unit, Amiens, France
- Amiens-Picardie University Medical Center, Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens, France
| | - Roberto Pecoits-Filho
- DOPPS Program Area, Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Cutitiba, PR, Brazil
| | - Ziad A Massy
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint-Quentin University, Inserm U1018 Clinical Epidemiology Team, Villejuif, France
- Ambroise Paré University Hospital, APHP, Department of Nephrology, Boulogne-Billancourt/Paris, France
| | - Bénédicte Stengel
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint-Quentin University, Inserm U1018 Clinical Epidemiology Team, Villejuif, France
| | - Natalia Alencar de Pinho
- Centre for research in Epidemiology and Population Health (CESP), Paris-Saclay University, Versailles Saint-Quentin University, Inserm U1018 Clinical Epidemiology Team, Villejuif, France
| | - Karen Leffondré
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
- University Bordeaux, INSERM, CIC-1401-EC, Bordeaux, France
| | - Mathilde Prezelin-Reydit
- University Bordeaux, INSERM, Bordeaux Population Health, UMR1219, Bordeaux, France
- University Bordeaux, INSERM, CIC-1401-EC, Bordeaux, France
- Maison du REIN AURAD Aquitaine, Néphrologie, Gradignan, Nouvelle-Aquitaine, FR
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Kuragano T, Okami S, Tanaka-Mizuno S, Uenaka H, Kimura T, Ishida Y, Yoshikawa-Ryan K, James G, Hayasaki T. Anemia Treatment, Hemoglobin Variability, and Clinical Events in Patients With Nondialysis-Dependent CKD in Japan. KIDNEY360 2023; 4:e1223-e1235. [PMID: 37424063 PMCID: PMC10547228 DOI: 10.34067/kid.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023]
Abstract
Key Points This large, contemporary study reports the management of anemia in a real-world cohort of patients with nondialysis-dependent CKD from multifaceted aspects. This study highlights the suboptimal and heterogeneous treatment of anemia in clinical practice. The findings also underscore the importance of maintaining a stable hemoglobin concentration within the target range to reduce the risk of mortality and morbidity. Background Anemia management in patients with nondialysis-dependent CKD has attracted attention with the introduction of novel therapeutic agents; however, few studies have provided comprehensive epidemiologic information. Methods A retrospective cohort study was conducted in adult patients with stage ≥3a nondialysis-dependent CKD and hemoglobin (Hb) <11 g/dl (January 2013–November 2021; N =26,626) to assess longitudinal treatment patterns, Hb, and iron parameters (ferritin and transferrin saturation) for anemia management. Time-dependent Cox proportional hazard models were applied to assess the risk of clinical events, including death, cardiovascular events, dialysis introduction, and red blood cell transfusion, associated with temporal fluctuation patterns of Hb levels. Results The cumulative incidence of anemia treatment initiation within 12 months was 37.1%, including erythropoiesis-stimulating agents 26.5%, iron oral 16.8%, iron intravenous 5.1%, and hypoxia-inducible factor prolyl hydroxylase inhibitor 0.2%. The mean (±SD) Hb levels were improved from 9.9±1.2 to 10.9±1.6 g/dl at 12 months. Despite erythropoiesis-stimulating agents or hypoxia-inducible factor prolyl hydroxylase inhibitor therapy, 30.1% of patients remained Hb <10 g/dl. The risks of premature death, cardiovascular events, dialysis introduction, and red blood cell transfusion were significantly higher in groups with consistently low Hb or low-amplitude Hb fluctuation around the lower limit of target Hb range than in patients with target Hb range (P < 0.05). Similarly, significantly higher risks for dialysis introduction and red blood cell transfusion were associated with high-amplitude Hb fluctuation across target Hb range were observed. Conclusions The findings underscore the importance of stable Hb control within the target range to reduce the mortality and morbidity risks in patients with nondialysis-dependent CKD while highlighting the suboptimal and heterogeneous treatment of anemia in clinical practice.
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Affiliation(s)
- Takahiro Kuragano
- Division of Kidney and Dialysis, Department of Internal Medicine, Nishinomiya, Hyogo Medical University, Hyogo, Japan
| | - Suguru Okami
- Medical Affairs & Pharmacovigilance, Kita-ku, Bayer Yakuhin, Ltd., Osaka, Japan
| | - Sachiko Tanaka-Mizuno
- Graduate School of Medicine and School of Public Health, Sakyo-ku, Kyoto University, Kyoto, Japan
- Research and Analytics Department, Nakagyo-ku, Real World Data Co. Ltd., Kyoto, Japan
| | - Hidetoshi Uenaka
- Research and Analytics Department, Nakagyo-ku, Real World Data Co. Ltd., Kyoto, Japan
| | - Takeshi Kimura
- Research and Analytics Department, Nakagyo-ku, Real World Data Co. Ltd., Kyoto, Japan
| | - Yosuke Ishida
- Medical Affairs & Pharmacovigilance, Kita-ku, Bayer Yakuhin, Ltd., Osaka, Japan
| | | | - Glen James
- Integrated Evidence Generation & Business Innovation, Bayer AG, Reading, United Kingdom
| | - Takanori Hayasaki
- Medical Affairs & Pharmacovigilance, Kita-ku, Bayer Yakuhin, Ltd., Osaka, Japan
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Minutolo R, Garofalo C, Chiodini P, Aucella F, Del Vecchio L, Locatelli F, Scaglione F, De Nicola L. Types of erythropoiesis-stimulating agents and risk of end-stage kidney disease and death in patients with non-dialysis chronic kidney disease. Nephrol Dial Transplant 2021; 36:267-274. [PMID: 32829405 DOI: 10.1093/ndt/gfaa088] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Despite the widespread use of erythropoiesis-stimulating agents (ESAs) to treat anaemia, the risk of adverse outcomes associated with the use of different types of ESAs in non-dialysis chronic kidney disease (CKD) is poorly investigated. METHODS From a pooled cohort of four observational studies, we selected CKD patients receiving short-acting (epoetin α/β; n = 299) or long-acting ESAs (darbepoetin and methoxy polyethylene glycol-epoetin β; n = 403). The primary composite endpoint was end-stage kidney disease (ESKD; dialysis or transplantation) or all-cause death. Multivariable Cox models were used to estimate the relative risk of the primary endpoint between short- and long-acting ESA users. RESULTS During follow-up [median 3.6 years (interquartile range 2.1-6.3)], the primary endpoint was registered in 401 patients [166 (72%) in the short-acting ESA group and 235 (58%) in the long-acting ESA group]. In the highest tertile of short-acting ESA dose, the adjusted risk of primary endpoint was 2-fold higher {hazard ratio [HR] 2.07 [95% confidence interval (CI) 1.37-3.12]} than in the lowest tertile, whereas it did not change across tertiles of dose for long-acting ESA patients. Furthermore, the comparison of ESA type in each tertile of ESA dose disclosed a significant difference only in the highest tertile, where the risk of the primary endpoint was significantly higher in patients receiving short-acting ESAs [HR 1.56 (95% CI 1.09-2.24); P = 0.016]. Results were confirmed when ESA dose was analysed as continuous variable with a significant difference in the primary endpoint between short- and long-acting ESAs for doses >105 IU/kg/week. CONCLUSIONS Among non-dialysis CKD patients, the use of a short-acting ESA may be associated with an increased risk of ESKD or death versus long-acting ESAs when higher ESA doses are prescribed.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlo Garofalo
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Filippo Aucella
- Department of Nephrology and Dialysis, IRCSS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | | | - Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, AlessandroManzoni Hospital, ASST Lecco, Lecco, Italy
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania Luigi Vanvitelli, Naples, Italy
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The Impact of CKD Anaemia on Patients: Incidence, Risk Factors, and Clinical Outcomes-A Systematic Literature Review. Int J Nephrol 2020; 2020:7692376. [PMID: 32665863 PMCID: PMC7349626 DOI: 10.1155/2020/7692376] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/25/2020] [Indexed: 12/15/2022] Open
Abstract
Anaemia is a common consequence of chronic kidney disease (CKD); however, the risk factors for its development and its impact on outcomes have not been well synthesised. Therefore, we undertook a systematic review to fully characterise the risk factors associated with the presence of anaemia in patients with CKD and a contemporary synthesis of the risks of adverse outcomes in patients with CKD and anaemia. We searched MEDLINE, EMBASE, and the Cochrane Library from 2002 until 2018 for studies reporting the incidence or prevalence of anaemia and associated risk factors and/or associations between haemoglobin (Hb) or anaemia and mortality, major adverse cardiac events (MACE), hospitalisation, or CKD progression in adult patients with CKD. Extracted data were summarised as risk factors related to the incidence or prevalence of anaemia or the risk (hazard ratio (HR)) of outcome by Hb level (<10, 10-12, >12 g/dL) in patients not on dialysis and in those receiving dialysis. 191 studies met the predefined inclusion criteria. The risk factor most associated with the prevalence of anaemia was CKD stage, followed by age and sex. Mean HRs (95% CI) for all-cause mortality in patients with CKD on dialysis with Hb <10, 10-12, and >12 g/dL were 1.56 (1.43-1.71), 1.17 (1.09-1.26), and 0.91 (0.87-0.96), respectively. Similar patterns were observed for nondialysis patients and for the risks of hospitalisation, MACE, and CKD progression. This is the first known systematic review to quantify the risk of adverse clinical outcomes based on Hb level in patients with CKD. Anaemia was consistently associated with greater mortality, hospitalisation, MACE, and CKD progression in patients with CKD, and risk increased with anaemia severity. Effective treatments that not only treat the anaemia but also reduce the risk of adverse clinical outcomes are essential to help reduce the burden of anaemia and its management in CKD.
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Ito K, Ookawara S, Ueda Y, Miyazawa H, Uchida T, Kofuji M, Hayasaka H, Minato S, Kaneko S, Mutsuyoshi Y, Yanai K, Ishii H, Matsuyama M, Kitano T, Shindo M, Aomatsu A, Hirai K, Hoshino T, Tabei K, Morishita Y. Cerebral oxygenation improvement is associated with hemoglobin increase after hemodialysis initiation. Int J Artif Organs 2020; 43:695-700. [PMID: 32141374 DOI: 10.1177/0391398820910751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Near-infrared spectroscopy has been used to measure the regional oxygen saturation (rSO2) of the brain, and decreases in cerebral rSO2 have been reported to lead to cognitive impairment in patients undergoing hemodialysis. However, reports about the association between changes in cerebral oxygenation and clinical parameters at hemodialysis initiation, including hemoglobin level, are lacking. METHODS This study included 33 patients at the hemodialysis initiation phase. Cerebral rSO2 was monitored using an INVOS 5100C. Included patients were assessed twice (at hemodialysis initiation and 42.7 ± 20.8 days after the first measurement), and changes in cerebral rSO2 were compared with changes in clinical parameters. RESULTS Cerebral rSO2 at the second measurement significantly increased compared with that at hemodialysis initiation (57.2 ± 6.8% vs 54.4 ± 8.8%, p < 0.05). Changes in cerebral rSO2 represented a significant correlation with changes in hemoglobin level, pulse rate, and serum albumin level. Multivariate linear regression analysis was performed using significant factors in simple linear regression analysis. Changes in hemoglobin (standardized coefficient: 0.37) and serum albumin (standardized coefficient: 0.45) levels were identified as independent factors influencing the changes in cerebral rSO2. CONCLUSION Cerebral rSO2 was low in the presence of low hemoglobin levels at hemodialysis initiation and improved in response to hemoglobin increase in addition to changes in serum albumin levels. Attention should be paid to changes in hemoglobin levels even at hemodialysis initiation to prevent the deterioration of cerebral oxygenation, and this might contribute to the maintenance of cognitive function in patients undergoing hemodialysis.
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Affiliation(s)
- Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takayuki Uchida
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaya Kofuji
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideyuki Hayasaka
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shohei Kaneko
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Mutsuyoshi
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Katsunori Yanai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroki Ishii
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Momoko Matsuyama
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akinori Aomatsu
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Minami-Uonuma City Hospital, Minamiuonuma, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Association between long-term hemoglobin variability and mortality in Korean adults: a nationwide population-based cohort study. Sci Rep 2019; 9:17285. [PMID: 31754187 PMCID: PMC6872712 DOI: 10.1038/s41598-019-53709-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022] Open
Abstract
Hemoglobin variability is known to be associated with mortality in patients with chronic renal failure and cardiovascular disease. However, the effect of hemoglobin variability on mortality in the general population has not yet been studied. We aimed to investigate the association between hemoglobin variability and mortality using Korean cohort from National Health Insurance Service-Health Screening 2002–2015 database. This study was conducted on 182,757 adults who underwent more than 4 health screenings from 2002 to 2009. Hemoglobin variability was assessed by 3 indices of coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM). Cox proportional hazard regression analysis was performed for each index of quartile groups (Q1–Q4). The hazard ratio and 95% confidence interval^l for all-cause mortality comparing Q2, Q3 and Q4 with Q1 of hemoglobin variability CV in the multivariable adjusted model were 1.07 [0.96–1.20], 1.18 [1.06–1.31] and 1.43 [1.29–1.58] respectively. As the 5% CV, SD, and VIM increased, the hazard ratio for mortality increased by 1.08 [1.06–1.10] in the multivariable adjusted model. Hemoglobin variability is not only important predictor in patients with chronic renal failure and cardiovascular disease but could also be considered as a useful predictor of mortality in the general population.
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Time-averaged hemoglobin values, not hemoglobin cycling, have an impact on outcomes in pediatric dialysis patients. Pediatr Nephrol 2018; 33:2143-2150. [PMID: 30105415 DOI: 10.1007/s00467-018-4013-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/19/2018] [Accepted: 06/25/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND During erythropoietin-stimulating agent (ESA) treatment, hemoglobin (Hb) levels usually fluctuate; this phenomenon is known as "Hb cycling (HC)." In this study, we aimed to evaluate the predictors of HC and its impact on left ventricular hypertrophy (LVH) as a patient-important outcome parameter in pediatric dialysis patients. METHODS Records of patients followed up in nine pediatric nephrology centers between 2008 and 2013 were reviewed. More than 1 g/dL decrease or increase in Hb level was considered as HC. Patients were divided into two groups according to 12-month Hb trajectory as rare cycling (RC) (≤ 3) and frequent cycling (FC) (> 3 fluctuation) as well as three groups based on T-A-Hb levels: < 10, 10-11, and > 11 g/dL. RESULTS Two hundred forty-five dialysis (160 peritoneal dialysis (PD) and 85 hemodialysis (HD)) patients aged 12.3 ± 5.1 (range 0.5-21) years were enrolled in this study. Fifty-two percent of the patients had RC, 45% had FC, and only 3% had no cycling. There were no differences between HC groups with respect to age, dialysis modality, having anemia, hospitalization rate, residual urine volume, and mortality. Although left ventricular mass index (LVMI) tended to be higher in RC than FC group (65 ± 37 vs 52 ± 23 g/m2.7, p = 0.056), prevalence of LVH was not different between the groups (p = 0.920). In regression analysis, FC was not a risk factor for LVH, but low T-A Hb level (< 10 g/dL) was a significant risk for LVH (OR = 0.414, 95% CI 0.177-0.966, p = 0.04). The target Hb levels were more often achieved in PD patients, and the number of deaths was significantly lower in non-anemic patients (Hb level > 11 g/dL). CONCLUSION Hb cycling is common among dialysis patients. Severity of anemia rather than its cycling has more significant impact on the prevalence of LVH and on inflammatory state.
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Lin FJ, Zhang X, Huang LS, Ji G, Huang HD, Xie Y, Jiang GR, Zhou X, Lu W. Impact of hemoglobin variability on cardiovascular mortality in maintenance hemodialysis patients. Int Urol Nephrol 2018; 50:1703-1712. [PMID: 29974406 DOI: 10.1007/s11255-018-1919-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/20/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Although the association between anemia and cardiovascular mortality in hemodialysis patients is well established, whether hemoglobin variability (Hgb-Var) affects the prognosis remains unclear. We aimed to evaluate the association between Hgb-Var and cardiovascular mortality in Chinese hemodialysis patients. METHODS This retrospective study included 252 patients starting hemodialysis in Xin Hua Hospital between January 2009 and December 2015. Patients were divided into three tertiles based on Hgb-Var, as reflected by SD Hgbmean, SD Hgbrange, and Hgbdeflection during a 12-month evaluation period after hemodialysis initiation. Left ventricular ejection fraction (EF) and left ventricular mass index (LVMI) were evaluated by echocardiography. Information on cardiovascular deaths occurred by December 2017 was collected. Multivariate Cox regression models were constructed to evaluate the association between Hgb-Var and cardiovascular mortality. RESULTS A total of 75 deaths and 52 cardiovascular deaths occurred during the 47-month follow-up (range 29.5-70). Under multivariate regression, the subgroup with the highest Hgb-Var had a higher risk of cardiovascular mortality after adjusting for relevant factors (HR vs. lowest SD Hgbmean: 9.15, 95% CI 2.82, 29.693, P < 0.0001; HR vs. lowest SD Hgbrange: 3.81, 95% CI 1.40, 10.38, P = 0.005). Per 1 SD of Hgbmean and Hgbrange elevations were both related to a 10% increase in the cardiovascular mortality risk. Baseline EF% and LVMI did not differ across the Hgb-Var subgroups. EF% upon the last patient visit to the clinic was lower in the subgroup with the highest SD Hgbmean (P = 0.02). CONCLUSIONS High Hgb-Var is an independent risk factor for cardiovascular mortality in hemodialysis patients and might influence the cardiac function.
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Affiliation(s)
- Fu-Jun Lin
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Xi Zhang
- Clinical Research Unit, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu-Sheng Huang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Gang Ji
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Hai-Dong Huang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Yun Xie
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Geng-Ru Jiang
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Xin Zhou
- Clinical Research Unit, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Wei Lu
- Renal Division, Department of Internal Medicine, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai, China.
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Variability in hemoglobin levels in hemodialysis patients in the current era: a retrospective cohort study. Clin Nephrol 2018; 88:254-265. [PMID: 28899480 PMCID: PMC5653974 DOI: 10.5414/cn109031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background: Given regulatory and reimbursement changes in anemia management, we examined hemoglobin variability in a contemporary cohort of maintenance hemodialysis patients. Materials and methods: 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, always-intermediate, always-high; variable patterns were: varying between low and intermediate, intermediate and high, low and high (most-variable). Cox proportional hazard models were used to assess the association between hemoglobin variability and all-cause mortality or major adverse cardiac events (MACE). Results: The 25th and 75th 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. Conclusions: 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.
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Goldfarb-Rumyantzev AS, Gautam S, Dong N, Brown RS. Prediction Model and Risk Stratification Tool for Survival in Patients With CKD. Kidney Int Rep 2018; 3:417-425. [PMID: 29725646 PMCID: PMC5932311 DOI: 10.1016/j.ekir.2017.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Because chronic kidney disease (CKD) adversely affects survival, prediction of mortality risk should help to identify individuals requiring therapeutic intervention. The goal of this project was to construct and to validate a risk scoring system and prediction model of the probability of 2-year mortality in a CKD population. METHODS We applied the Woodpecker approach to develop prediction equations using linear, exponential, and combined models. A risk indicator R on a scale of 0 to 10 was calculated as follows: starting with 0, add 0.048 for each year of age above 20, 0.45 for male sex, 0.49 for each stage of CKD over stage 2, 1.04 for proteinuria, 0.72 for smoking history, and 0.49 for each significant comorbidity up to 5. RESULTS Using R to predict 2-year mortality, the model yielded an area under the receiver operating characterisic curve of 0.83 (95% confidence interval = 0.81-0.86) with 5062 subjects with CKD ≥stage 2 from a National Health and Nutrition Examination Survey cohort (1999-2004) having a 3.2% 2-year mortality. The combined expression offered results closest to most actual outcomes for the entire population and for each CKD stage. For those patients with higher risk (R ≥ 4-5, >5-6, and >6), the predicted 2-year mortality rates were 3.8%, 6.4%, and 13.0%, respectively, compared to observed mortality rates of 2.7%, 4.5%, and 13.3%. CONCLUSION The risk stratification tool and prediction model of 2-year mortality demonstrated good performance and may be used in clinical practice to quantify the risk of death for individual patients with CKD.
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Affiliation(s)
| | - Shiva Gautam
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Ning Dong
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Robert S. Brown
- Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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11
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Sumida K, Diskin CD, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Rhee CM, Streja E, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Pre-End-Stage Renal Disease Hemoglobin Variability Predicts Post-End-Stage Renal Disease Mortality in Patients Transitioning to Dialysis. Am J Nephrol 2017; 46:397-407. [PMID: 29130991 DOI: 10.1159/000484356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 10/12/2017] [Indexed: 02/01/2023]
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.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Charles Dyer Diskin
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
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12
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Nakazato Y, Kurane R, Hirose S, Watanabe A, Shimoyama H. Aging and death-associated changes in serum albumin variability over the course of chronic hemodialysis treatment. PLoS One 2017; 12:e0185216. [PMID: 28953942 PMCID: PMC5617180 DOI: 10.1371/journal.pone.0185216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 09/10/2017] [Indexed: 11/19/2022] Open
Abstract
Background Several epidemiological studies have demonstrated associations between variability in a number of biological parameters and adverse outcomes. As the variability may reflect impaired homeostatic regulation, we assessed albumin variability over time in chronic hemodialysis (HD) patients. Methods Data from 1346 subjects who received chronic HD treatment from May 2001 to February 2015 were analyzed according to three phases of HD treatment: post-HD initiation, during maintenance HD treatment, and before death. The serum albumin values were grouped according to the time interval from HD initiation or death, and the yearly trends for both the albumin levels and the intra-individual albumin variability (quantified by the residual coefficient of variation: Alb-rCV) were examined. The HD initiation and death-associated changes were also analyzed using generalized additive mixed models. Furthermore, the long-term trend throughout the maintenance treatment period was evaluated separately using linear regression models. Results Albumin levels and variability showed distinctive changes during each of the 3 periods. After HD initiation, albumin variability decreased and reached a nadir within a year. During the subsequent maintenance treatment period (interquartile range = 5.2–11.0 years), the log Alb-rCV showed a significant upward trend (mean slope: 0.011 ± 0.035 /year), and its overall mean was -1.49 ± 0.08 (equivalent to an Alb-rCV of 3.22%). During the 1–2 years before death, this upward trend clearly accelerated, and the mean log Alb-rCV in the last year of life was -1.36 ± 0.17. The albumin levels and variability were negatively correlated with each other and exhibited exactly opposite movements throughout the course of chronic HD treatment. Different from the albumin levels, albumin variability was not dependent on chronological age but was independently associated with an individual’s aging and death process. Conclusion The observed upward trend in albumin variability seems to be consistent with a presumed aging-related decline in homeostatic capacity.
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Affiliation(s)
- Yuichi Nakazato
- Division of Nephrology, Yuai Nisshin Clinic, Hakuyukai Medical Corporation, Saitama-City, Saitama, Japan
- * E-mail:
| | - Riichi Kurane
- Division of Nephrology, Yuai Clinic, Hakuyukai Medical Corporation, Saitama-City, Saitama, Japan
| | - Satoru Hirose
- Division of Nephrology, Yuai Mihashi Clinic, Hakuyukai Medical Corporation, Saitama-City, Saitama, Japan
| | - Akihisa Watanabe
- Division of Nephrology, Yuai Nakagawa Clinic, Hakuyukai Medical Corporation, Saitama-City, Saitama, Japan
| | - Hiromi Shimoyama
- Division of Nephrology, Yuai Clinic, Hakuyukai Medical Corporation, Saitama-City, Saitama, Japan
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13
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Ganidagli SE, Altunoren O, Erken E, Isık IO, Ganidagli B, Eren N, Yavuz YC, Gungor O. The relation between hemoglobin variability and carotid intima-media thickness in chronic hemodialysis patients. Int Urol Nephrol 2017; 49:1859-1866. [PMID: 28711962 DOI: 10.1007/s11255-017-1651-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/04/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Hemoglobin variability is a common problem among hemodialysis patients. We have previously demonstrated an association between Hb variability and left ventricular mass index. In this study, we investigated a possible relation between Hb variability and carotid intima-media thickness (CIMT). METHODS Twelve-month hemoglobin (Hb) values of 135 patients on maintenance hemodialysis were examined retrospectively. The range of 11-12 gr/dl was accepted as normal according to the KDOQI guidelines. Hemoglobin levels were classified as: Hb < 11 gr/dl:Low, Hb = 11-12 gr/dl:Normal and Hb > 12 gr/dl:High. According to 12-month Hb trajectory, the patients were divided into three groups: low-normal (LN), normal-high (NH) and low-high (LH). The CIMT measurements were taken on common carotid arteries bilaterally, and the average of these measurements were taken. The groups were compared in terms of CIMT measurements, demographic and laboratory features. RESULTS The LN, NH and LH groups were similar in terms of age, gender, incidence of diabetes mellitus, hypertension and cardiovascular diseases. Duration of hemodialysis, hemodialysis adequacy, serum lipids and CaxP products were also similar among the groups. The mean CIMT value was 0.601 ± 0.107, 0.744 ± 0.139 and 0.604 ± 0.134 mm in the LN, LH and NH groups, respectively (p < 0.001). CIMT was significantly higher in LH than in the other two groups. CONCLUSIONS In our study, when the three groups with similar risk factors for atherosclerosis were examined, we found that the LH group with the highest hemoglobin variability has the highest CIMT. This study is the first study to demonstrate that Hb variability is associated with an increase in CIMT in HD patients.
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Affiliation(s)
- Safa Ersen Ganidagli
- Faculty of Medicine, Internal Medicine Department, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey
| | - Orcun Altunoren
- Faculty of Medicine, Nephrology Department, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey.
| | - Ertuğrul Erken
- Faculty of Medicine, Nephrology Department, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey
| | - Ismet Onder Isık
- FMC Kahramanmaras Dialysis Center, Internalist, Kahramanmaraş, Turkey
| | - Berivan Ganidagli
- Faculty of Medicine, Internal Medicine Department, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey
| | - Necmi Eren
- Faculty of Medicine, Nephrology Department, Kocaeli University, Izmit, Turkey
| | | | - Ozkan Gungor
- Faculty of Medicine, Nephrology Department, Kahramanmaras Sutcu Imam University, Kahramanmaraş, Turkey
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14
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Vadadustat, a novel oral HIF stabilizer, provides effective anemia treatment in nondialysis-dependent chronic kidney disease. Kidney Int 2016; 90:1115-1122. [DOI: 10.1016/j.kint.2016.07.019] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/29/2016] [Accepted: 07/14/2016] [Indexed: 12/17/2022]
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15
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Smyth B, Knight JF, Herrington WG. The rise and rise of randomized clinical evidence in Sub-Saharan Africa. Clin Kidney J 2016; 9:814-816. [PMID: 27994860 PMCID: PMC5162410 DOI: 10.1093/ckj/sfw084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 07/27/2016] [Indexed: 12/11/2022] Open
Abstract
Sub-Saharan Africa is facing a rising tide of chronic disease, including chronic kidney disease, but the current research literature provides little evidence to guide the practice of nephrology in resource-poor settings. In this issue of CKJ, Waziri & Bello present a trial of two formulations of intravenous iron for patients with anaemia of chronic kidney disease in Nigeria. This study typifies a growing body of work from researchers from low-middle income countries addressing the evidence gaps that they meet in their everyday practice. Collaboration with clinical trialists and health economists from the global renal research community is suggested as an important way to expand, at low cost, the randomized evidence-base in this region.
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Affiliation(s)
- Brendan Smyth
- Renal & Metabolic Division, George Institute for Global Health, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - John F Knight
- Renal & Metabolic Division, George Institute for Global Health, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Abstract
Improved understanding of the oxygen-dependent regulation of erythropoiesis has provided new insights into the pathogenesis of anaemia associated with renal failure and has led to the development of novel therapeutic agents for its treatment. Hypoxia-inducible factor (HIF)-2 is a key regulator of erythropoiesis and iron metabolism. HIF-2 is activated by hypoxic conditions and controls the production of erythropoietin by renal peritubular interstitial fibroblast-like cells and hepatocytes. In anaemia associated with renal disease, erythropoiesis is suppressed due to inadequate erythropoietin production in the kidney, inflammation and iron deficiency; however, pharmacologic agents that activate the HIF axis could provide a physiologic approach to the treatment of renal anaemia by mimicking hypoxia responses that coordinate erythropoiesis with iron metabolism. This Review discusses the functional inter-relationships between erythropoietin, iron and inflammatory mediators under physiologic conditions and in relation to the pathogenesis of renal anaemia, as well as recent insights into the molecular and cellular basis of erythropoietin production in the kidney. It furthermore provides a detailed overview of current clinical experience with pharmacologic activators of HIF signalling as a novel comprehensive and physiologic approach to the treatment of anaemia.
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He L, Fu M, Chen X, Liu H, Chen X, Peng X, Liu F, Peng Y. Effect of dialysis dose and membrane flux on hemoglobin cycling in hemodialysis patients. Hemodial Int 2014; 19:263-9. [PMID: 25215434 DOI: 10.1111/hdi.12215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many studies found that hemoglobin (Hb) fluctuation was closely related to the prognosis of the maintenance hemodialysis patients. We investigated the association of factors relating dialysis dose and dialyzer membrane with Hb levels. We undertook a randomized clinical trial in 140 patients undergoing thrice-weekly dialysis and assigned patients randomly to a standard or high dose of dialysis; Hb level was measured every month for 12 months. In the standard-dose group, the mean (±SD) urea reduction ratio was 65.1% ± 7.3%, the single-pool Kt/V was 1.26 ± 0.11, and the equilibrated Kt/V was 1.05 ± 0.09; in the high-dose group, the values were 73.5% ± 8.7%, 1.68 ± 0.15, and 1.47 ± 0.11, respectively. The standard deviation (SD) and residual SD (liner regression of Hb) values of Hb were significantly higher in the standard-dose group and low-flux group. The percentage achievement of target Hb in the high-dose dialysis group and high-flux dialyzer group was significantly higher than the standard-dose group and low-flux group, respectively. Patients undergoing hemodialysis thrice weekly appear to have benefit from a higher dialysis dose than that recommended by current KDQQI (Kidney Disease Qutcome Quality Initiative) guidelines or from the use of a high-flux membrane, which is in favor of maintaining stable Hb levels.
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Affiliation(s)
- Liyu He
- Key Laboratory of Kidney Disease and Blood Purification in Hunan, Nephrology Department, 2nd Xiangya Hospital, Central South University, Changsha, Hunan, China
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18
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Beneficial dose conversion after switching from higher doses of shorter-acting erythropoiesis-stimulating agents to C.E.R.A in CKD patients in clinical practice: MINERVA Study. Int Urol Nephrol 2014; 46:1983-95. [PMID: 25118611 DOI: 10.1007/s11255-014-0800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/24/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess whether the correction dose recommended by the summary of product characteristics was adequate and to confirm the adequacy of the recommended conversion dosing strategies from shorter-acting erythropoiesis-stimulating agents (ESAs) to continuous erythropoietin receptor activator (C.E.R.A) in anaemic chronic kidney disease (CKD) patients in the clinical setting. METHODS This was a 12-month, multicenter, prospective, observational study in anaemic CKD patients on haemodialysis and not on dialysis receiving C.E.R.A (at least one dose). RESULTS A total of 227 patients were included (not on dialysis; n = 142; haemodialysis: n = 85). The present analysis was conducted on ESA-naïve patients (not on dialysis: n = 31) and patients switched from other ESA (not on dialysis: n = 63; haemodialysis: n = 57). Both on and not on dialysis patients switched from other ESA received lower starting C.E.R.A doses than those recommended, and remained stable during the 12-month period. The higher the previous ESA dose was, the more beneficial the C.E.R.A dose conversion factor was. The proportion of patients with stable haemoglobin within the target range (11-13 g/dL) did not vary during the 12-month period both in nondialysis CKD patients and in those undergoing dialysis [baseline: 42 (66.7 %) and 34 (59.6 %); month 6: 21 (55.3 %) and 26 (50.0 %); month 12: 20 (64.5 %) and 25 (69.4 %), respectively]. In naïve patients, the mean weight-adjusted C.E.R.A dose during the study (1.19 ± 0.49 µg/kg/month) was similar to the recommended one. C.E.R.A was well tolerated. CONCLUSIONS Conversion from shorter-acting ESAs to C.E.R.A doses lower than those recommended can efficiently maintain target haemoglobin levels both in nondialysis and haemodialysis CKD patients, particularly when switching from higher ESA doses. A monthly C.E.R.A dose of 1.2 µg/Kg seems adequate for anaemia correction.
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Altunoren O, Dogan E, Sayarlioglu H, Acar G, Yavuz YC, Aydın N, Sahin M, Akkoyun M, Isik IO, Altunoren O. Effect of hemoglobin variability on mortality and some cardiovascular parameters in hemodialysis patients. Ren Fail 2014; 35:819-24. [PMID: 23751144 DOI: 10.3109/0886022x.2013.801270] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most hemodialysis patients show hemoglobin fluctuations between low-normal and high levels. This hemoglobin variability may cause left ventricle hypertrophy and may increase mortality as well. Recently, many studies were designed to evaluate the effect of hemoglobin variability on mortality but results were conflicting. We aimed to investigate the effect of hemoglobin variability on mortality and some cardiovascular parameters in hemodialysis population. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS Hundred and seventy-five prevalent hemodialysis patients classified into three hemoglobin variability groups according to their hemoglobin levels throughout 24 month observation period: Low-Normal, Low-High, Normal-High. Groups were compared in terms of laboratory, demographical data and mortality rates, initial and the end of 24 month echocardiographic data. Initial and last echocardiographic data were compared within groups in terms of left ventricle mass index increase. RESULTS Mortality rates and cardiovascular risk factors such as coronary heart disease, diabetes mellitus and hypertension that may affect mortality were same between three groups. There was no significant difference between three groups in terms of echocardiographic and laboratory parameters. Only Low-High group showed significant increase on left ventricle mass index when initial and last echocardiographic parameters were compared. CONCLUSIONS Consistent with previous studies, we found that most of the patients exhibited hemoglobin variability and our study is consistent with some of the studies that did not find any relationship between hemoglobin variability and mortality. Firstly, in this study based on objective data, it was shown that hemoglobin variability has adverse effect on left ventricle geometry independent from anemia.
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Affiliation(s)
- Orcun Altunoren
- Department of Nephrolory, Faculty of Medicine, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey.
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20
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Moist LM, Troyanov S, White CT, Wazny LD, Wilson JA, McFarlane P, Harwood L, Sood MM, Soroka SD, Bass A, Manns BJ. Canadian Society of Nephrology Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis 2013; 62:860-73. [DOI: 10.1053/j.ajkd.2013.08.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/07/2013] [Indexed: 12/22/2022]
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Stavinoha A, Modem V, Quigley R. Using noninvasive hemoglobin measurements to estimate measured hemoglobin in a pediatric hemodialysis unit. Hemodial Int 2013; 17 Suppl 1:S7-10. [DOI: 10.1111/hdi.12082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Rozen-Zvi B, Ben-Avraham B, Schneider S, Gafter-Gvili A, Levy-Drummer RS, Zingerman B, Mor E, Gafter U, Rahamimov R. Haemoglobin variability in the early post-transplant period: association with graft survival and mortality. Nephrology (Carlton) 2013; 18:148-56. [PMID: 23134202 DOI: 10.1111/nep.12009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2012] [Indexed: 11/28/2022]
Abstract
AIM Haemoglobin (Hb) variability is associated with poor survival in patients with chronic kidney disease. Association of Hb variability after kidney transplantation with patients' and graft survival has not been adequetly studied. METHODS This retrospective study used registry data to examine the association between Hb variability in the early post-transplant period (first 6 months) and graft survival after kidney transplantatin. Kaplan-Meier and Cox regression analyses were used for univariate and multivariate associations between mortality, death censored graft survival and the composite outcome of both, in 752 patients after kidney transplantation. Hb values were collected each month during the first 6 months after transplantation, and Hb variavility was calculated using the residual standard deviation method. RESULTS The highest quartile of Hb variability was associated with inferior graft and patients' survival in univariate (hazard ratio (HR) 2.18; 95% confidence interval (CI) 1.51 to 3.13; P < 0.001) and multivariate models (HR 1.5; 95% CI 1.029 to 2.18; P = 0.035). This association was mainly due to increased death censored graft failure in the high variability group (HR 2.75; 95% CI 1.73 to 4.38; P < 0.001) and (HR 1.67; 95% CI 1.023 to 2.74; P = 0.04) in the univariate and multivariate models, respectively. There was no association between Hb variability and the risk of death (HR 1.51; 95% CI 0.88 to 2.57; P = 0.132). CONCLUSION High Hb variability is independently associated with inferior graft survival in patients after kidney transplantation.
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Affiliation(s)
- Benaya Rozen-Zvi
- Nephrology and Hypertension, Rabin Medical Center, Petah Tikva, Israel.
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Wu IW, Hsu KH, Lee CC, Sun CY, Hsu HJ, Hung MJ, Wu MS. Re-evaluating the predictive roles of metabolic complications and clinical outcome according to eGFR levels--a four-years prospective cohort study in Taiwan. BMC Nephrol 2013; 14:92. [PMID: 23607513 PMCID: PMC3643890 DOI: 10.1186/1471-2369-14-92] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 03/20/2013] [Indexed: 11/12/2022] Open
Abstract
Background Metabolic complications are associated with clinical outcomes in patients with chronic kidney disease (CKD). These outcomes differ among patients according to the different stages of disease. The prevalence and association of type and number of metabolic complications with renal progression and death in patients having different eGFR levels has high clinical value, but this fact has been rarely evaluated in prospective studies. Methods We prospectively followed a cohort of 1157 CKD patients from 2006 to death or until 2010, and evaluated the prevalence of CKD-related complications and their association with renal progression (defined as a decline in eGFR by > 50% from baseline, or end-stage renal disease requiring dialysis) and death in patients with eGFRs above and below 45 mL/min/1.73 m2 using Cox-proportional hazard models. Results The estimated rate (per 100 patient-years) of renal progression and death were 11.9 and 4.9, respectively. The eGFR thresholds determined by ROC analysis with a sensitivity of 90% for any metabolic complication were 60.8 mL/min/1.73 m2 and 74.3 mL/min/1.73 m2 using the MDRD and CKD Epidemiology Collaboration equations, respectively. CKD-related complications associated with renal progression in patients having eGFR < 45 mL/min/1.73 m2 were hyperphosphatemia, anemia, microinflammation and hypoalbuminemia. Those CKD-related complications associated with death were hypoalbuminemia and hyperuricemia. Hypoalbuminemia predicted renal progression, and, hypoalbuminemia and microinflammation predicted death in patients with eGFR ≥ 45 mL/min/1.73 m2. The number of complications (≥ 3) independently predicted both endpoints in patients with eGFR < 45 mL/min/1.73 m2. Conclusions Hypoalbuminemia was a unique and strong predictor of renal progression and all-cause mortality in CKD patients, independent of their demographic characteristics, traditional risk factors, renal function severity, the presence of cardiovascular disease and other metabolic abnormalities. Most other metabolic complications and the number of complications (≥3) were associated with the clinical outcomes of patients with eGFR < 45 mL/min/1.73 m2 rather than in those with higher eGFRs. The findings from the present study offer a novel insight into the association between metabolic complications and patient outcomes and may help to refine risk stratification according to disease stage.
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Affiliation(s)
- I-Wen Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
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Morosetti M, Gorini A, Costanzo AM, Cipriani S, Dominijanni S, Egan CG, Zappalà L, di Luzio Paparatti U. Clinical management of nondialysis patients with chronic kidney disease: a retrospective observational study. Data from the SONDA study (Survey Of Non-Dialysis outpAtients). Int J Nephrol Renovasc Dis 2013; 6:27-37. [PMID: 23550080 PMCID: PMC3579409 DOI: 10.2147/ijnrd.s38405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background A lack of awareness of chronic kidney disease (CKD) often results in delayed diagnosis and inadequate treatment. Purpose The objective of this study was to assess the therapeutic management and outcome of nondialysis CKD patients. Methods Three hundred ninety-seven patients (54.9% males aged 67.5 ± 14.6 years) were retrospectively screened at the Nephrology Department, GB Grassi Hospital, Rome, Italy. After a baseline visit, patient data were collected every 6 months for a total of 24 months. Clinical characteristics were measured at baseline, then the following outcomes were measured every 6 months: staging of CKD, presence of concomitant diseases, treatment and adherence to Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines for anemia management. Results Three hundred sixty-eight (92.7%) patients attended at least one visit and 92 (23.2%) patients attended all four visits. Patients were mainly referred to a nephrologist for chronic renal failure (61.7%) or hypertension (42.8%). At baseline, 79.6% of patients had previous hospitalization and 79.1% were receiving antihypertensive medication. Serum creatinine and/or glomerular filtration rate was examined in >90% of patients, whereas parathyroid hormone was rarely examined (5.5%). Vitamin D supplementation was received by 6.5% of patients. The majority of patients were staged at 3 or 4 CKD (32% and 23.9%, respectively) and did not significantly change over time. The use of antithrombotic, antilipidemic and erythropoietin medication increased over the four surveys. The majority of patients (86.8%) achieved hemoglobin K/DOQI target levels. Conclusion These findings demonstrate a current lack of attention of CKD and related disorders (mineral metabolism, electrolyte balance, and anemia) at the level of the general practitioner (GP) and non-nephrology specialist, which can result in both delayed referral and inadequate treatment. By increasing both awareness of CKD and the coordinated relationship between GPs and nephrologists, patient clinical and therapeutic outcome may be improved.
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Affiliation(s)
- Massimo Morosetti
- Nephrology and Dialysis Department, 'G.B. Grassi' Hospital, Ostia Lido, Rome, Italy
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Minutolo R, Conte G, Cianciaruso B, Bellizzi V, Camocardi A, De Paola L, De Nicola L. Hyporesponsiveness to erythropoiesis-stimulating agents and renal survival in non-dialysis CKD patients. Nephrol Dial Transplant 2012; 27:2880-6. [PMID: 22319218 DOI: 10.1093/ndt/gfs007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lower responsiveness to erythropoiesis-stimulating agents (ESA-R) predicts cardiovascular (CV) events. Whether ESA-R also affects the risk of end-stage renal disease (ESRD) is unknown. METHODS We evaluated ESA-R in 194 consecutive chronic kidney disease (CKD) patients, regularly seen in outpatient nephrology clinics, who started erythropoiesis-stimulating agent (ESA) therapy between 2002-06. Exclusion criteria were causes of anaemia other than CKD or recent transfusion. ESA-R was calculated as (Hb1-Hb0)/time/ESA dose (g/dL/month/10 μg/week of ESA). Patients were classified, from lower to higher tertile of ESA-R, as poor, intermediate and good responders. Time to ESRD was the primary outcome. RESULTS Age was 64±16 years, 48% were male, 34% had diabetes and 32% had CV disease, glomerular filtration rate (GFR) 24±13 mL/min/1.73 m2 and proteinuria 0.6 g/dL (interquartile range 0.2-1.9). First ESA dose was 23.7±10.8 μg/week; haemoglobin (Hb) increased from 9.9±0.8 g/dL to 11.0±1.2 g/dL at first control, obtained after 1.4±0.4 months. These changes corresponded to an ESA-R of 0.37±0.38 g/dL/month/10 μg/week of ESA and tertiles limits were 0.17 and 0.47. Poor responders were younger and had lower GFR and higher proteinuria than intermediate and good responders. During the first 6 months of ESA therapy, poor responders showed lower Hb levels and sustained longer periods of Hb level<11 g/dL. During follow-up (median 3.0 years), 99 patients reached ESRD. At multivariable Cox's analysis, poor responsiveness was associated with higher risk of ESRD (hazard ratio 2.49, 95% confidence interval 1.28-4.84). CONCLUSION ESA-R predicts renal prognosis in CKD patients followed in nephrology practice, where ESRD is the predominant outcome and ESA is commonly used at low dose.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, Second University of Naples, Naples, Italy.
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Galle JC, Claes K, Kiss I, Winearls CG, Herlitz H, Guerin A, Di Giulio S, Suranyi MG, Bridges I, Addison J, Farouk M. An observational cohort study of extended dosing (once every 2 weeks or once monthly) regimens with darbepoetin alfa in patients with chronic kidney disease not on dialysis: the EXTEND study. Nephrol Dial Transplant 2011; 27:2303-11. [PMID: 22140136 PMCID: PMC3363980 DOI: 10.1093/ndt/gfr677] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background. Darbepoetin alfa (DA) has been shown to be an effective treatment of anaemia in patients with chronic kidney disease (CKD) not on dialysis (NoD). EXTEND is an observational study assessing the effectiveness of DA administered once biweekly (Q2W) or monthly (QM) in a general CKD-NoD population. Methods. Adult CKD-NoD patients starting DA Q2W/QM treatment in June 2006 or later were eligible. Retrospective and/or prospective data including haemoglobin levels and erythropoiesis-stimulating agent (ESA) dosing were collected for 6 months before and 12 months after DA initiation. Mean Hb levels were calculated every 3 months, and ESA dose was converted to a geometric mean weekly DA equivalent dose and summarized monthly. Results. Data from 4278 patients showed that patients receiving ESA treatment before DA Q2W/QM initiation had a mean (95% confidence interval) Hb level of 11.9 g/dL (11.8–12.0 g/dL) at initiation and 11.6 g/dL (11.6–11.7 g/dL) at Months 10–12, with mean ESA dose of 22 μg/week (21–23 μg/week) prior to initiation, 16 μg/week (15–16 μg/week) at initiation and 16 μg/week (15–16 μg/week) at Month 12. In ESA-naive patients, Hb levels increased from 10.3 g/dL (10.2–10.3 g/dL) at initiation to 11.7 g/dL at Months 4–6 and were maintained at a mean level of 11.7 g/dL (11.7–11.8 g/dL) at Months 10–12, with mean ESA dose of 16 μg/week (16–17 μg/week) at initiation and 16 μg/week (16–17 μg/week) at Month 12. In the 85% of patients receiving DA at extended intervals (Q2W or less frequently) at Month 12, 12 patients (0.3%) experienced DA-related adverse reactions. Conclusion. DA Q2W/QM was an effective treatment of anaemia in the general CKD-NoD patient population and a dose increase was not required in patients switching from a previous ESA regimen.
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Affiliation(s)
- Jan-Christoph Galle
- Klinik für Nephrologie und Dialyseverfahren, Klinikum Lüdenscheid, Lüdenscheid, Germany.
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Trkulja V. Treating anemia associated with chronic renal failure with erythropoiesis stimulators: recombinant human erythropoietin might be the best among the available choices. Med Hypotheses 2011; 78:157-61. [PMID: 22078846 DOI: 10.1016/j.mehy.2011.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 09/11/2011] [Accepted: 10/12/2011] [Indexed: 11/26/2022]
Abstract
Chronic renal failure (CRF) is a widespread medical problem commonly accompanied by a hypoproliferative anemia ("renal anemia") due to erythropoietin deficiency. Anemia greatly contributes to reduced quality of life (Hr-QoL) and high morbidity and mortality in CRF patients. Recombinant human erythropoietin (rHu-Epo) was introduced to medical practice some 20years ago. It enables correction of anemia (hemoglobin levels, Hb) with dramatic immediate (Hr-QoL improvement) and long-term effects (reduced morbidity and mortality). Newer experimental data suggest that long-term benefits could be due not only to antianemic effect, but also to a direct organoprotective effect of (rHu)-Epo mediated through a receptor complex different from the "erythropoietic" erythropoietin receptor. During the last decade, two alternative treatments for renal anemia have been approved: darbepoetin and CERA. Both are direct agonists of the "erythropoietic" receptors and both were derived from rHu-Epo. Molecularly, they differ from rHu-Epo in that they are much larger molecules (darbepoetin is genetically modified rHu-Epo with a higher sugar content and CERA is pegylated rHu-Epo) with lower affinity for the erythropoietin receptor but with a longer circulating time. In terms of renal anemia correction, they are non-inferior to rHu-Epo and allow for less frequent dosing. They have never been compared to rHu-Epo regarding the long-term outcomes. It is hypothesized that regarding the long-term outcomes (morbidity, mortality), rHu-Epo might be superior to those larger molecules. The hypothesis is based on two types of observations. First, experimental data emphasize the role of small, erythropoietically less valuable rHu-Epo isoforms in its organoprotective effects. Second, clinical observations suggest that rHu-Epo enables for less variable Hb correction than the larger molecules, and pronounced within-subject Hb variability has been suggested as an independent predictor of poor long-term outcomes of renal anemia management.
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Affiliation(s)
- Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Šalata 11, 10000 Zagreb, Croatia.
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Szeto CC, Kwan BCH, Chow KM, Pang WF, Leung CB, Li PKT. Haemoglobin variability in Chinese pre-dialysis CKD patients not receiving erythropoietin. Nephrol Dial Transplant 2011; 26:2919-2924. [DOI: 10.1093/ndt/gfq824] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Pisoni RL, Bragg-Gresham JL, Fuller DS, Morgenstern H, Canaud B, Locatelli F, Li Y, Gillespie B, Wolfe RA, Port FK, Robinson BM. Facility-level interpatient hemoglobin variability in hemodialysis centers participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS): Associations with mortality, patient characteristics, and facility practices. Am J Kidney Dis 2011; 57:266-75. [PMID: 21251541 DOI: 10.1053/j.ajkd.2010.11.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 11/07/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hemodialysis patients with larger hemoglobin level fluctuations have higher mortality rates. We describe facility-level interpatient hemoglobin variability, its relation to patient mortality, and factors associated with facility-level hemoglobin variability or achieving hemoglobin levels of 10.5-12.0 g/dL. Facility-level hemoglobin variability may reflect within-patient hemoglobin variability and facility-level anemia-control practices. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS; 26,510 hemodialysis patients, 930 facilities, 12 countries, 1996-2008) and from the Centers for Medicare & Medicaid Services (CMS; 193,291 hemodialysis patients, 3,741 US facilities, 2002). PREDICTORS Standard deviation (SD) in single-measurement hemoglobin levels in hemodialysis patients in facility cross-sections (facility-level hemoglobin SD); patient characteristics; facility practices. OUTCOMES Patient-level mortality; additionally, facility practices correlated with facility-level hemoglobin SD or patient hemoglobin levels of 10.5-12.0 g/dL. RESULTS Facility-level hemoglobin SD varied more than 5-fold across DOPPS facilities (range, 0.5-2.7 g/dL; mean, 1.3 g/dL) and by country (range, 1.1 in Japan-DOPPS [2005/2006] to 1.7 g/dL in Spain-DOPPS [1998/1999]), with substantial decreases seen in many countries from 1998 to 2007. Facility-level hemoglobin SD was related inversely to patient age, but was associated minimally with more than 30 other patient characteristics and facility mean hemoglobin levels. Several anemia management practices were associated strongly with facility-level hemoglobin SD and having a hemoglobin level of 10.5-12.0 g/dL. When examined in CMS data, facility-level hemoglobin SD was positively associated with within-patient hemoglobin SD during the prior 6 months. Patient mortality rates were higher with greater facility-level hemoglobin SD (DOPPS: HR, 1.08 per 0.5-g/dL greater facility-level hemoglobin SD [95% CI, 1.02-1.15; P = 0.006]; CMS: HR, 1.16 per 0.5-g/dL greater facility-level hemoglobin SD [95% CI, 1.11-1.21; P < 0. 001]). LIMITATIONS Residual confounding. CONCLUSIONS Facility-level hemoglobin SD was associated strongly and positively with patient mortality, not tightly linked to numerous patient characteristics, but related strongly to facility anemia management practices. Facility-level hemoglobin variability may be modifiable and its optimization may improve hemodialysis patient survival.
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Affiliation(s)
- Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA.
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de Francisco ALM. Individualizing anaemia therapy. NDT Plus 2010; 3:519-26. [PMID: 25949459 PMCID: PMC4421434 DOI: 10.1093/ndtplus/sfq164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 08/04/2010] [Accepted: 08/25/2010] [Indexed: 11/13/2022] Open
Abstract
Individualized strategies for managing renal anaemia with erythropoiesis-stimulating agents (ESAs) need to be advanced. Recent outcomes from clinical studies prompted a narrowing of the guideline-recommended haemoglobin target (11-12 g/dL) due to increased mortality and morbidity when targeting higher haemoglobin concentrations. Maintaining a narrow target is a clinical challenge, as haemoglobin concentration tends to fluctuate. The goal of individualized treatment is to achieve the haemoglobin target at the lowest ESA dose while avoiding significant fluctuations in haemoglobin concentrations and persistently low or high concentrations. This may require changes to the ESA dose and dosing frequency over the course of treatment.
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Affiliation(s)
- Angel L M de Francisco
- Servicio de Nefrologia , Hospital Marques de Valdecilla de Santander , Santander , Spain
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Eckardt KU, Kim J, Kronenberg F, Aljama P, Anker SD, Canaud B, Molemans B, Stenvinkel P, Schernthaner G, Ireland E, Fouqueray B, Macdougall IC. Hemoglobin variability does not predict mortality in European hemodialysis patients. J Am Soc Nephrol 2010; 21:1765-75. [PMID: 20798262 DOI: 10.1681/asn.2009101017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Patients with CKD exhibit significant within-patient hemoglobin (Hb) level variability, especially with the use of erythropoiesis stimulating agents (ESAs) and iron. Analyses of dialysis cohorts in the United States produced conflicting results regarding the association of Hb variability with patient outcomes. Here, we determined Hb variability in 5037 European hemodialysis (HD) patients treated over 2 years to identify predictors of high variability and to evaluate its association with all-cause and cardiovascular disease (CVD) mortality. We assessed Hb variability with various methods using SD, residual SD, time-in-target (11.0 to 12.5 g/dl), fluctuation across thresholds, and area under the curve (AUC). Hb variability was significantly greater among incident patients than prevalent patients. Compared with previously described cohorts in the United States, residual SD was similar but fluctuations above target were less frequent. Using logistic regression, age, body mass index, CVD history, dialysis vintage, serum albumin, Hb, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use, ESA use, dialysis access type, dialysis access change, and hospitalizations were significant predictors of high variability. Multivariable adjusted Cox regression showed that SD, residual SD, time-in-target, and AUC did not predict all-cause or CVD mortality during a median follow-up of 12.4 months (IQR: 7.7 to 17.4). However, patients with consistently low levels of Hb (<11 g/dl) and those who fluctuated between the target range and <11 g/dl had increased risks for death (RR 2.34; 95% CI: 1.24 to 4.41 and RR 1.74; 95% CI: 1.00 to 3.04, respectively). In conclusion, although Hb variability is common in European HD patients, it does not independently predict mortality.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany.
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Gaweda AE, Nathanson BH, Jacobs AA, Aronoff GR, Germain MJ, Brier ME. Determining optimum hemoglobin sampling for anemia management from every-treatment data. Clin J Am Soc Nephrol 2010; 5:1939-45. [PMID: 20671221 DOI: 10.2215/cjn.03540410] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Anemia management protocols in ESRD call for hemoglobin (Hb) monitoring every 2 to 4 weeks. Short-term Hb variability affects the reliability of Hb measurement and may lead to incorrect dosing of erythropoiesis stimulating agents. We prospectively analyzed short-term Hb variability and quantified the relationship between frequency of Hb monitoring and error in Hb estimation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the Crit-Line III TQA device, we prospectively observed Hb during each dialysis treatment in 49 ESRD patients and quantified long- and short-term Hb variability. We estimated Hb from data sampled at regular intervals; 8×, 4×, 2×, or 1× per month to establish how well we account for short-term variability at different monitoring intervals. We calculated the Hb estimation error (Hb(err)) as a root mean-squared difference between the observed and estimated Hb and compared it with the measurement error. RESULTS The most accurate Hb estimation is achieved when monitoring 8× per month (Hb(err) = 0.23 ± 0.05 g/dl), but it exceeds the accuracy of the measurement device. The estimation error increases to 0.34 ± 0.07 g/dl when monitoring 4× per month, 0.39 ± 0.08 g/dl when monitoring 2× a month, and 0.45 ± 0.09 g/dl when monitoring 1× per month. Estimation error comparable to instrument error information is as follows: 8× per month, 15 patients; 4× per month, 22 patients; 2× per month, 6 patients; 1× per a month, 6 patients. CONCLUSIONS Four times a month is the clinically optimal Hb monitoring frequency for anemia management.
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Affiliation(s)
- Adam E Gaweda
- University of Louisville, Department of Medicine, Louisville, KY 40202, USA.
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Van Wyck DB, Alcorn H, Gupta R. Analytical and biological variation in measures of anemia and iron status in patients treated with maintenance hemodialysis. Am J Kidney Dis 2010; 56:540-6. [PMID: 20638166 DOI: 10.1053/j.ajkd.2010.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 05/05/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND To make informed decisions in dosing erythropoiesis-stimulating agents and intravenous iron therapy, clinicians must determine whether differences between current and previous test results for anemia and iron status markers reflect expected variation, a significant change, or an actual trend. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 30 patients undergoing thrice-weekly in-center hemodialysis. PREDICTOR Within-patient biological variations in hemoglobin (Hb) level, hematocrit (Hct), reticulocyte Hb content, transferrin saturation (TSAT), and ferritin level were determined over 12 consecutive treatment days. OUTCOMES & MEASUREMENTS We separately measured same-sample analytical variation and within-patient biological variation (coefficient of variation), then calculated the number of sampling days needed to determine the true or homeostatic value for each analyte with 95% probability. We also evaluated whether results differed among the first, second, and third dialysis days of the week. RESULTS Biological variation differed by analyte. Hb level (4.0%), Hct (4.0%), and reticulocyte Hb content (4.8%) showed much lower variation than TSAT (38.2%) or ferritin level (15.1%). Analytical variation ranged from 2.0%-6.9% for all analytes. We found that one sample day would be sufficient to establish the true mean Hb level or Hct within a level of closeness+/-20% and 95% probability. For the same levels of closeness and probability, one sample day would be needed for reticulocyte Hb content, 15 for TSAT, and 3 for ferritin level. No pairwise comparison for any of the 5 analytes yielded a significant difference between results obtained on the first, second, or third dialysis day of the week. LIMITATIONS These findings may not apply to other patient populations. CONCLUSIONS Low biological variation renders Hb level, Hct, and reticulocyte Hb content, but not TSAT and ferritin level, suitable for trend analysis using results from 2 successive samples. TSAT and ferritin test results, unlike reticulocyte Hb content, have limited value in evaluating changes in iron status within individual hemodialysis patients.
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Lau JH, Gangji AS, Rabbat CG, Brimble KS. Impact of haemoglobin and erythropoietin dose changes on mortality: a secondary analysis of results from a randomized anaemia management trial. Nephrol Dial Transplant 2010; 25:4002-9. [PMID: 20530806 DOI: 10.1093/ndt/gfq330] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anaemia is a common complication of chronic kidney disease. A number of studies have identified an adverse association between haemoglobin (Hgb) variability and mortality. To date, no study has evaluated the impact of Hgb variability on mortality in the setting of a uniform Hgb target and erythropoiesis-stimulating agents (ESA) dosing strategy. METHODS One hundred and fifty-four haemodialysis (HD) patients from a previous randomized anaemia management study were followed up for up to 6 years. The impact of Hgb variability and ESA dosing parameters on subsequent mortality risk were evaluated. RESULTS More rapid rises in Hgb (Hgb deflect(pos)) and ESA dose increases were independently associated with mortality in multivariate analysis, whereas more rapid Hgb declines (Hgb deflect(neg)) and ESA dose decreases were not. Each gram per litre per week increase in Hgb deflect(pos) was associated with an adjusted hazard ratio (HR) of 1.23 (1.03-1.48), while for every 1000-unit increase in ESA dose, the adjusted HR was 1.12 (1.01-1.24). Factors associated with positive Hgb deflections included frequency and magnitude of ESA dose changes, baseline Hgb, patient weight and presence of an HD catheter. CONCLUSIONS Rapid Hgb rises and greater average Eprex dose increases were independently associated with a higher mortality risk in HD patients after adjustment for baseline Hgb and Eprex dose. A randomized controlled trial evaluating different ESA dosing strategies in response to individual patient ESA responsiveness is needed.
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Affiliation(s)
- Joanne H Lau
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
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Verhelst D. Actualités dans la prise en charge de l’anémie Congrès mondial de Néphrologie 2009. Nephrol Ther 2010; 6:1-9. [DOI: 10.1016/s1769-7255(10)70008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Singh AK. The FDA's perspective on the risk for rapid rise in hemoglobin in treating CKD anemia: Quo Vadis. Clin J Am Soc Nephrol 2010; 5:553-6. [PMID: 20203166 DOI: 10.2215/cjn.00490110] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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van der Putten K, van der Baan FH, Schellekens H, Gaillard CAJM. Hemoglobin variability in patients with chronic kidney disease in the Netherlands. Int J Artif Organs 2010; 32:787-93. [PMID: 20020410 DOI: 10.1177/039139880903201104] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Hemoglobin cycling has been reported in hemodialysis patients treated with erythropoiesis-stimulating agents (ESA) and is associated with increased mortality. Information on hemoglobin cycling in Europe is limited. We investigated hemoglobin variability in the Netherlands. Hemodialysis and peritoneal dialysis patients were studied and pre-dialysis patients were enrolled. METHODS This observational retrospective study was executed in a Dutch dialysis center. We studied 157 patients from 2005 to 2007: 56 hemodialysis, 12 peritoneal dialysis and 29 pre-dialysis patients, all treated with ESA; and 60 pre-dialysis patients without ESA. Patients were divided on the basis of their pattern of hemoglobin fluctuation around a range of 11-12 g/dL. In dialysis patients, the amount of time that hemoglobin remained within that range was calculated. For all patients, the magnitude of hemoglobin fluctuations was assessed (i.e. the difference between hemoglobin maximum and minimum) and data on ESA dose changes and hospitalizations were collected. RESULTS None of the ESA treated patients had hemoglobin levels stable within the target range over a one-year period. Pre-dialysis patients without ESA also showed variable hemoglobin levels. A stepwise decrease in the magnitudes of hemoglobin fluctuation was observed in the hemodialysis patients, peritoneal dialysis patients, pre-dialysis patients using ESA, and the pre-dialysis patients without ESA, respectively. CONCLUSION In the Netherlands, hemoglobin variability is common in hemodialysis and peritoneal dialysis patients, but also in pre-dialysis patients. The results of this study warrant further research into the relationship between hemoglobin variability and clinical outcomes.
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Affiliation(s)
- Karien van der Putten
- Department of Internal Medicine, Meander Medical Center, Amersfoort - the Netherlands
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