American Journal of Kidney Diseases
Volume 54, Issue 3 , Pages 498-510, September 2009

Anemia Management and Association of Race With Mortality and Hospitalization in a Large Not-for-Profit Dialysis Organization

  • Karen S. Servilla, MD

      Affiliations

    • Nephrology Section, New Mexico Veterans Affairs Health Care System, Albuquerque, NM
    • Dialysis Clinic Inc Quality Management Division, Albuquerque, NM
    • University of New Mexico Health Sciences Center, Albuquerque, NM
    • ,
  • Ajay K. Singh, MD

      Affiliations

    • Renal Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
    • ,
  • William C. Hunt, MA

      Affiliations

    • Dialysis Clinic Inc Quality Management Division, Albuquerque, NM
    • ,
  • Antonia M. Harford, MD

      Affiliations

    • University of New Mexico Health Sciences Center, Albuquerque, NM
    • ,
  • Dana Miskulin, MD, MS

      Affiliations

    • Tufts Medical Center, Boston, MA
    • ,
  • Klemens B. Meyer, MD

      Affiliations

    • Tufts Medical Center, Boston, MA
    • ,
  • Edward J. Bedrick, PhD

      Affiliations

    • Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM
    • ,
  • Mark R. Rohrscheib, MD

      Affiliations

    • University of New Mexico Health Sciences Center, Albuquerque, NM
    • ,
  • Antonios H. Tzamaloukas, MD

      Affiliations

    • Nephrology Section, New Mexico Veterans Affairs Health Care System, Albuquerque, NM
    • ,
  • H. Keith Johnson, MD

      Affiliations

    • Dialysis Clinic Inc, Nashville, TN
    • ,
  • Philip G. Zager, MD

      Affiliations

    • Dialysis Clinic Inc Quality Management Division, Albuquerque, NM
    • University of New Mexico Health Sciences Center, Albuquerque, NM
    • Corresponding Author InformationAddress correspondence to Philip G. Zager, MD, University of New Mexico, Department of Internal Medicine, 1500 Indian School Rd NE, Ste 200, Albuquerque NM 87102

Received 7 November 2008; accepted 14 May 2009. published online 24 July 2009.

Background

The optimal hemoglobin target and possible toxicity of epoetin therapy in hemodialysis patients are controversial. Previous studies suggest that African American patients use higher doses of epoetin and have better survival compared with white hemodialysis patients.

Study Design

Retrospective longitudinal cohort.

Setting & Participants

Epoetin-exposed incident hemodialysis patients (N = 12,733; African Americans, n = 4,801; white, n = 7,386) treated in Dialysis Clinic Inc facilities during 2000 to 2006.

Predictors

Hemoglobin, epoetin, iron.

Outcomes

Mortality, hospitalization.

Measurements

Proportional hazards models with time-varying covariates.

Results

Hemoglobin concentrations less than 10 g/dL in whites and less than 11 g/dL in African Americans were associated with increased mortality and hospitalization versus the referent hemoglobin level of 11 to 11.9 g/dL. Hemoglobin levels of 13 g/dL or greater in whites were associated with decreased noncardiovascular mortality. Six-month cumulative epoetin doses of 20,000 U/wk or greater were associated with increased mortality and hospitalization versus the referent group (8,000 to 12,499 U/wk). Epoetin doses less than 8,000 U/wk were associated with decreased risk. Higher epoetin doses were associated with increased mortality at hemoglobin concentrations of 10 to 12.9 g/dL and with increased hospitalization at all hemoglobin concentrations of 10 g/dL or greater. Higher epoetin doses were associated with increased mortality and hospitalization within each tertile of serum albumin concentration. These patterns did not differ by race.

Limitations

Treatment-by-indication bias and unidentified confounders cannot be excluded. Small sample sizes in the highest and lowest hemoglobin strata decrease statistical power.

Conclusions

Relationships between hemoglobin concentration and mortality differed between African Americans and whites. Additionally, the relationship of lower mortality with greater achieved hemoglobin concentration seen in white patients was observed for all-cause, but not cardiovascular, mortality. A higher cumulative epoetin dose was associated with worse outcomes, even in patients with albumin levels greater than 4 g/dL. There were no statistically significant interactions between race and epoetin dose. Further studies are needed to confirm and to define the mechanism of these findings.

Index Words: Epoetin, hemoglobin, mortality, hospitalization, hemodialysis

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 Originally published online as doi: 10.1053/j.ajkd.2009.05.007 on July 24, 2009.

 Because the Editor-in-Chief and Deputy Editor recused themselves from consideration of this manuscript, the peer-review and decision-making processes were handled entirely by a Co-Editor (James S. Kaufman, MD, Renal Section, Veterans Affairs Boston Healthcare System and Boston University School of Medicine, Boston, MA) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.

PII: S0272-6386(09)00772-0

doi:10.1053/j.ajkd.2009.05.007

American Journal of Kidney Diseases
Volume 54, Issue 3 , Pages 498-510, September 2009

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