Dataset Information

Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients.

ABSTRACT:

Background

Randomized trials found that use of erythropoiesis-stimulating agents to target normal hematocrit (Hct) levels (>39%) compared with 27%-34.5% increases cardiovascular risk and mortality among chronic kidney disease patients. However, the effects of the most widely used Hct target in the past 2 decades, 34.5%-39%, have never been examined.

Objective

To compare the effects of 2 Hct target strategies-30.0%-34.5% (low) and 34.5%-39.0% (mid) in a high-risk population: elderly dialysis patients with significant comorbidities.

Research design

Observational data from the US Renal Data System were used to emulate a randomized trial in which patients were assigned to either Hct strategy. Follow-up started after completing 3 months of hemodialysis and ended 6 months later. We conducted the observational analogs of intention-to-treat and per-protocol analyses. Inverse-probability weighting was used to adjust for measured time-dependent confounding by indication.

Subjects

A total of 22,474 elderly patients with both diabetes and cardiovascular disease who initiated hemodialysis in 2006-2008.

Measures

Hazard ratios (HRs) and survival probabilities for all-cause mortality and a composite cardiovascular and mortality endpoint.

Results

The intention-to-treat HR (95% confidence interval) for mid versus low Hct strategy was 1.05 (0.99-1.11) for all-cause mortality and 1.03 (0.98-1.08) for the composite endpoint. The per-protocol HR (95% confidence interval) for mid versus low Hct strategy was 0.98 (0.78-1.24) for all-cause mortality and 1.00 (0.81-1.24) for the composite outcome.

Conclusions

Among hemodialysis patients, we did not find differences in 6-month survival or cardiovascular risk between clinical strategies that target Hct at 30.0%-34.5% versus 34.5%-39.0%.

SUBMITTER: Zhang Y

PROVIDER: S-EPMC3933821 | biostudies-literature | 2014 Mar

REPOSITORIES: biostudies-literature

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Publications

Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients.

Zhang Yi Y Thamer Mae M Kaufman James J Cotter Dennis D Hernán Miguel A MA

Medical care 20140301

<h4>Background</h4>Randomized trials found that use of erythropoiesis-stimulating agents to target normal hematocrit (Hct) levels (>39%) compared with 27%-34.5% increases cardiovascular risk and mortality among chronic kidney disease patients. However, the effects of the most widely used Hct target in the past 2 decades, 34.5%-39%, have never been examined.<h4>Objective</h4>To compare the effects of 2 Hct target strategies-30.0%-34.5% (low) and 34.5%-39.0% (mid) in a high-risk population: elderl ...[more]

PMID: 24561752

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Project description:BackgroundAnemia is a major comorbidity of patients with end-stage renal disease and poses an enormous economic burden to health-care systems. High dose erythropoiesis-stimulating agents (ESAs) have been associated with unfavorable clinical outcomes. We explored whether mixed-dilution hemodiafiltration (Mixed-HDF), based on its innovative substitution modality, may improve anemia outcomes compared to the traditional post-dilution hemodiafiltration (Post-HDF).MethodsWe included 174 adult prevalent dialysis patients (87 on Mixed-HDF, 87 on Post-HDF) treated in 24 NephroCare dialysis centers between January 2010 and August 2016 into this retrospective cohort study. All patients were dialyzed three times per week and had fistula/graft as vascular access. Patients were matched at baseline and followed over a one-year period. The courses of hemoglobin levels (Hb) and monthly ESA consumption were compared between the two groups with linear mixed models.ResultsMean baseline Hb was 11.9±1.3 and 11.8±1.1g/dl in patients on Mixed- and Post-HDF, respectively. While Hb remained stable in patients on Mixed-HDF, it decreased slightly in patients on Post-HDF (at month 12: 11.8±1.2 vs 11.1±1.2g/dl). This tendency was confirmed by our linear mixed model (p = 0.0514 for treatment x time interaction). Baseline median ESA consumption was 6000 [Q1:0;Q3:16000] IU/4 weeks in both groups. Throughout the observation period ESA doses tended to be lower in the Mixed-HDF group (4000 [Q1:0;Q3:16000] vs 8000 [Q1:0;Q3:20000] IU/4 weeks at month 12; p = 0.0791 for treatment x time interaction). Sensitivity analyses, adjusting for differences not covered by matching at baseline, strengthened our results (Hb: p = 0.0124; ESA: p = 0.0687).ConclusionsResults of our explorative study suggest that patients on Mixed-HDF may have clinical benefits in terms of anemia management. This may also have a beneficial economic impact. Future studies are needed to confirm our hypothesis-generating results and to provide additional evidence on the potential beneficial effects of Mixed-HDF.

Project description:BackgroundPatients with kidney failure undergoing dialysis often suffer from anemia. Iron deficiency, along with a shortage in erythropoietin, is a common cause. Peritoneal dialysis (PD) patients may have a different iron metabolism compared to hemodialysis (HD) patients. This study aims to compare both dialysis modalities regarding their differences in iron management.MethodsPubMed (MEDLINE) and Embase were screened for randomized controlled trials and observational studies including both patients on HD or PD with information on iron management. Outcomes for iron management for this systematic review included: prevalence of supplementation, route of administration, dose, frequency and hemoglobin and iron status parameters.Results15 eligible studies (930,436 patients), of which 8 cohort and 7 cross-sectional, were analyzed. The prevalence of intravenous (IV) iron supplementation ranged from 11.7% to 84.4% in HD patients, compared to 1.6% to 49.0% in PD patients. Ten studies reported that HD patients only received IV iron, while five studies reported this for PD patients. For oral iron supplementation, three studies involved HD patients, whereas seven studies involved PD patients. The cumulative monthly IV iron dose ranged from 108 to 750 mg in the HD group, compared to 65 to 250 mg in the PD group. Hemoglobin levels ranged from 10.0 to 12.0 g/dL in HD patients, versus 9.6 to 11.9 g/dL in PD patients.ConclusionIron management differs between HD and PD patients, with HD patients receiving higher doses and more frequent IV iron. There was significant heterogeneity in the outcomes between the studies, primarily due to the lack of a uniform global policy on iron management. Despite these differences, hemoglobin levels and iron status parameters were comparable between the two groups. Future research should explore the underlying mechanisms and broader impacts of iron treatment, including patient-reported outcomes, to optimize anemia management and improve quality of life for dialysis patients.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42022336970.

Dataset Information

Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients.

Background

Objective

Research design

Subjects

Measures

Results

Conclusions

Publications

Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients.

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