Abstract
BackgroundThe change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%.ObjectiveThe aim of this study was to analyze the impact of loosening the erythropoietin payment criteria for peritoneal dialysis patients on their cardiovascular outcomes.MethodsTwo cohorts of incident peritoneal dialysis patients were identified according to the time before and after relaxation of the NHI’s erythropoietin payment criteria, designated cohort 1 (n=1759) and cohort 2 (n=2981), respectively. The cohorts were matched according to propensity scores (1754 patients in each cohort) and then followed up for cardiovascular events, which were analyzed with Cox regressions.ResultsFor the composite cardiovascular endpoint, patients in cohort 2 had a significantly lower risk than those in cohort 1. However, subgroup analysis showed that this risk reduction was observed only in patients with diabetes.ConclusionsAfter loosening erythropoietin payment criteria, reduced cardiovascular risks were observed, particularly for patients with diabetes. These results indicate that it is crucial to maintain an Hct level above 30% to reduce the cardiovascular risk in patients with diabetes undergoing peritoneal dialysis.
Highlights
Erythropoietin is a major regulatory hormone of erythrocyte production that is produced from the kidney, and its levels are decreased in patients with chronic kidney disease (CKD)
The estimate of diabetes status represented the cardiovascular risk of patients with diabetes relative to that of patients without diabetes in the time period of cohort 1, and the estimate of the interaction term measured the change in cardiovascular risk of patients with diabetes relative to that of patients without diabetes in the time period of cohort 2 compared to the time period of cohort 1. These results showed that the incident peritoneal dialysis patients with diabetes had a significant 78% higher cardiovascular risk than those of patients without diabetes
After loosening the erythropoietin payment criteria, a significantly lower risk of cardiovascular events, stroke, and heart failure hospitalization was observed in matched cohort 2, in particular for those with diabetes mellitus
Summary
Erythropoietin is a major regulatory hormone of erythrocyte production that is produced from the kidney, and its levels are decreased in patients with chronic kidney disease (CKD). More recent large, randomized outcome trials [1,2,3] showed that elevating the Hct level above 36% compared to maintaining Hct in the range of 30%-36% was associated with a higher risk of cardiovascular events for patients with CKD. These findings led to establishing the limitation of the Hct upper bound; the optimal Hct target remains debatable. The change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%
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