Original investigations
Dialysis therapies
Epoetin requirements predict mortality in hemodialysis patients

https://doi.org/10.1053/j.ajkd.2004.08.002Get rights and content

Background: Anemia is a frequent complication of end-stage renal disease. Poor responsiveness to epoetin therapy hampers the management of anemia. Escalating epoetin doses often are used to overcome epoetin resistance. The objective of this study is to examine the relationship between epoetin dose requirements and mortality. Methods: Using United States Renal Data System administrative claims data, we conducted a retrospective cohort study of 94,569 prevalent hemodialysis patients in 2000 and 2001. A Cox proportional hazard regression analysis, adjusted for baseline variables, and a 5-knot cubic regression spline were used to model the dose-response relationship between epoetin and all-cause mortality. Results: Significant interpatient variation exists in epoetin dose requirements to attain defined hematocrit levels. For every hematocrit cohort studied, patients administered higher doses of epoetin had significantly lower hematocrit values and greater mortality rates. Using the cubic spline function, a significant nonlinear relationship between increased epoetin dose and mortality was found regardless of hematocrit (P < 0.0001), with the steepest increase in relative risk for death found after the 72.5th dose percentile. Conclusion: Epoetin dose requirement is an independent predictor of total mortality in hemodialysis patients after adjustment for hematocrit. Poor responders who continue to have low hematocrit values despite the administration of high epoetin doses may not necessarily benefit from more epoetin, but perhaps should be considered for other adjunctive therapies. In contrast to conventional wisdom, this study suggests that epoetin dosing requirements could provide important prognostic information beyond that predicted by hematocrit alone.

Section snippets

Data sources

This study used data collected and maintained by the United States Renal Data System (USRDS). This database incorporates extensive baseline and follow-up demographic and clinical data on patients with ESRD whose care is covered by the Medicare program. Patient demographic and treatment characteristics, which include date of first ESRD service, age, sex, race, underlying disease causing ESRD, date of death, and date of first kidney transplant, were obtained from the PATIENTS file in the USRDS

General patient characteristics

We identified 145,606 prevalent adult hemodialysis patients between September 1, 2000, and December 31, 2000. Of these patients, 39,795 patients did not have 4 epoetin claims, 3,564 patients reported a type of dialysis other than hemodialysis during the entry period, 1,723 patients received a transplant before the beginning of the follow-up period, and 2,279 patients died during the entry period. Of the remaining 98,245 patients, an additional 3,676 patients were excluded because of missing URR

Discussion

In this retrospective analysis based on administrative data, we examine the relation of epoetin treatment and other baseline variables, including hematocrit, to mortality in 94,569 prevalent hemodialysis patients. Our analysis indicates considerable interpatient variability in dosing requirements for a defined hematocrit level. This result confirms previous studies showing a wide range of epoetin dose necessary to reach the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative

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    The data reported here have been supplied by the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as the official policy or interpretation of the US Government.

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