Abstract
Whether and how anemia treatment with erythropoiesis stimulating agents (ESAs) before hemodialysis initiation may be associated with lower mortality after dialysis initiation is unknown. We compared all-cause and cardiovascular mortality in two groups of patients who experienced distinct anemia treatment patterns with ESAs before and after hemodialysis initiation. This retrospective cohort analysis included patients initiating hemodialysis April 1, 2012-June 30, 2013, identified from United States Renal Data System end-stage renal disease (ESRD) and pre-ESRD files. Patients treated with ESAs before and after hemodialysis initiation who maintained Hb ≥ 9.0 g/dL throughout (comparator group, n = 3662) were compared with patients with Hb < 9.0 g/dL before hemodialysis initiation (with or without ESAs) whose levels increased with ESAs after hemodialysis initiation (referent group, n = 4461). Cox proportional hazards models were used to calculate the hazard ratio of all-cause and cardiovascular mortality after hemodialysis initiation. Of 20,454 patients, 4855 (23.7%) had Hb < 9.0 g/dL upon hemodialysis initiation; of these 4855, 26.6% received ESAs before initiation. Comparator group Hb levels increased from 8.2 ± 0.8 mg/dL upon initiation to 10.9 ± 1.2 with ESAs afterward. Comparator patients were more likely than referent patients to be younger (76.3 ± 6.7 versus 77.2 ± 6.9 years), male (51.5% versus 49.8%), and black (24.6% versus 18.6%). Risk of all-cause mortality was lower for the comparator group versus the referent group at 3 (HR 0.83, 95% CI 0.68–1.00, P = 0.052), 6 (0.86, 0.74–1.00, P = 0.047), and 12 (0.88, 0.78–0.99, P = 0.036) months. The pattern was similar for cardiovascular mortality. Hb ≥ 9.0 with ESAs before and after hemodialysis initiation was generally associated with lower post-initiation all-cause and cardiovascular mortality compared with predialysis Hb < 9.0 g/dL in patients whose Hb levels subsequently improved with ESAs after hemodialysis initiation.
Highlights
Anemia management is a cornerstone of care for patients with advanced chronic kidney disease (CKD)
Because our goal was to examine the association of outcomes between two groups of patients who appeared to be fundamentally comparable except for predialysis anemia management, our main contrast of interest was between groups 2 and 3, all four groups were retained for analysis
Group 2 comprised the 3662 patients who were treated with erythropoiesis-stimulating agents (ESAs) both before and after dialysis initiation and who maintained Hb levels ! 9.0 g/dL both before and after hemodialysis initiation
Summary
Anemia management is a cornerstone of care for patients with advanced chronic kidney disease (CKD). In the setting of maintenance hemodialysis, treatment with erythropoiesis-stimulating agents (ESAs) is ubiquitous [1,2,3,4]. Anemia is common in predialysis patients with advanced CKD [5,6]. Such patients are typically treated in outpatient office settings, where protocols for administering ESAs may be used less often and with less rigor than in dialysis units. Anemia is associated with mortality in patients receiving maintenance dialysis [7]. Regardless, the months following hemodialysis initiation are characterized by high mortality rates [10] and by concerted efforts to increase low Hb levels
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