Variability in Hemoglobin Levels and the Factors Associated with Mortality in Hemodialysis Patients: A 78-Month Follow-Up Study.

Natalino Salgado Filho,Joyce Lages,Dyego Brito,Francival De Souza,Gyl Silva,Erika Carneiro,Ricardo Sesso,Elton Santos,Alcione Dos Santos,Giselle Silva,Vinícius Mendes,Monique Muniz

doi:10.3390/ijerph18031078

Abstract

Some studies have described that when the hemoglobin levels of chronic kidney disease (CKD) patients change, especially in those taking erythropoiesis-stimulating agents (ESA), they are associated with unfavorable outcomes such as increased morbidity and mortality, mainly due to cardiovascular events. This prospective cohort study included patients with end-stage renal disease currently undergoing hemodialysis. The initial 6-month clinical evaluation provided data of the variability in hemoglobin, associated blood parameters, and the use of erythropoietin. Subsequently, the patients were followed up for 78 months to evaluate mortality-associated factors. In total, 133 patients completed the 6-month follow-up with a mean age of 47.1 (±13.2) years. The majority were women (51.9%). Six-month hemoglobin levels were as follows: always low (18.0%), intermediate/target (1.5%), always high (0.8%), low-amplitude fluctuation/Hb low (n = 37; 27.8%), low-amplitude fluctuation/Hb high (13.53%), and high-amplitude fluctuation (38.6%), among end-stage renal disease patients. At the end of 78 months, 50 (37.6%) patients died; 70% of deaths were attributed to cardiovascular etiologies. A high variability was observed in hemoglobin levels, which was not associated with mortality. Among all the variables evaluated, age, erythropoietin dose, and transferrin saturation were associated with a higher mortality. Thus, this study suggests that greater attention to erythropoietin doses and transferrin saturation levels may improve the survival of dialysis patients.

Highlights

In accordance with the above associations between changes in hemoglobin levels and the risks for cardiovascular events, we aimed to evaluate the variability of hemoglobin and the factors associated with the mortality of patients on hemodialysis during a 78-month follow-up period
This study aimed to evaluate the variability of hemoglobin and the factors associated with the mortality of patients on hemodialysis and found that among all the variables evaluated, age, erythropoietin dose, and transferrin saturation were associated with a higher mortality in patients with stage 5 chronic kidney disease
No association was observed between hemoglobin levels or its variations and the mortality of patients during a 78-month follow-up period

Summary

Introduction

The management of anemia has become central to the treatment of patients with chronic kidney disease (CKD) under dialysis. Observational studies show that patients experience considerable changes in hemoglobin levels over time, with only 5% of them being able to maintain normal levels (Hb 11–12 g/dL) during a 6-month period [1,2,3]. Ebben et al reported that only 10.3% of patients with stage 5 chronic kidney disease had stable hemoglobin levels during a 6-month study duration and only 6.5% of patients had their hemoglobin levels in the target range of 11–12 g/dL [4].

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