Secondary Hyperparathyroidism and Anemia in Children Treated by Hemodialysis

Smith, Lorie B.; Fadrowski, Jeffrey J.; Howe, Chanelle J.; Fivush, Barbara A.; Neu, Alicia M.; Furth, Susan L.

doi:10.1053/j.ajkd.2009.09.033

« Previous Next »American Journal of Kidney Diseases
Volume 55, Issue 2 , Pages 326-334, February 2010

Secondary Hyperparathyroidism and Anemia in Children Treated by Hemodialysis

Lorie B. Smith, MD, MHS
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
- Address correspondence to Lorie B. Smith, MD, MHS, 200 N Wolfe St, Rm 3055, Baltimore, MD 21287
Jeffrey J. Fadrowski, MD, MHS
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
Chanelle J. Howe, PhD, MHS, MPH
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Barbara A. Fivush, MD
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
Alicia M. Neu, MD
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
Susan L. Furth, MD, PhD
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD

Received 6 May 2009; accepted 28 September 2009.

Background

Many patients treated using hemodialysis remain anemic despite exogenous erythropoietin therapy, suggesting that the anemia experienced by these patients is multifactorial in cause. Iron deficiency, infection, inflammation, and malnutrition have been implicated in this process. Additionally, secondary hyperparathyroidism has been associated with anemia in adults, but few data exist about this topic in children.

Study Design

Cross-sectional retrospective.

Setting & Participants

Children treated in hemodialysis centers (N = 588) within the Centers for Medicare & Medicaid Services' 2002 Clinical Performance Measures Project.

Predictor

Intact parathyroid hormone (iPTH) levels assessed in October, November, and December 2001 and categorized as quintiles.

Outcomes & Measurements

Achievement of serum hemoglobin level ≥ 11 g/dL was assessed using Poisson regression adjusting for sex, age, race, dialysis vintage, vascular access type, single-pool Kt/V, serum albumin level, normalized protein catabolic rate, calcium-phosphorus product, and erythropoietin alfa dose.

Results

Using the second quintile (iPTH, 103-224 pg/mL) as the reference quintile, there was no association between iPTH quintile and achievement of the hemoglobin goal: quintile 1 prevalence ratio, 1.0 (95% CI, 0.9-1.2); quintile 3, 0.95 (95% CI, 0.8-1.1); quintile 4, 0.99 (95% CI, 0.8-1.2); and quintile 5, 0.97 (95% CI, 0.8-1.1). Only serum albumin level ≥ 3.5 g/dL (bromocresol green assay method) or ≥ 3.2 g/dL (bromocresol purple assay method) was significantly associated with meeting the hemoglobin goal: 1.4 (95% CI, 1.2-1.6).

Limitations

The simultaneous collection of iPTH and hemoglobin limits causal inference. Iron stores and iron therapy are potential confounders not accounted for in this study.

Conclusions

In the largest study of this topic in children, no association was found between iPTH level and achievement of a hemoglobin level ≥ 11 g/dL. Serum albumin level was associated strongly with achievement of the hemoglobin goal.

Index Words: Secondary hyperparathyroidism, anemia, hemodialysis