Prevalence of anemia in erythropoietin-treated pediatric as compared to adult chronic dialysis patients

BACKGROUND: Recent guidelines recommend a target hemoglobin range of 11 to 12 g/dL in pediatric and adult dialysis patients. We compared anemia prevalence in United States Medicare pediatric and adult dialysis patients. METHODS: Prevalent hemodialysis patients (0 to 19 years, pediatric: N= 1692; adult: N= 352,291) and peritoneal dialysis patients (pediatric: N= 597; adult: N= 39,136) treated with recombinant human erythropoietin (rHuEPO) from 1996 to 2000 were selected. Mean annual hemoglobin values were calculated by modality, age, sex, and race. RESULTS: Among hemodialysis patients, mean annual hemoglobin values less than 11 g/dL were present in pediatric and adult patients during 54.1% versus 39.8% patient years, respectively (P < 0.0001); for peritoneal dialysis patients, 69.5% versus 55.1% (P < 0.0001). Mean hemoglobin values increased over time and were 11.2, 11.5, 10.8, and 11.2 g/dL for pediatric and adult hemodialysis and peritoneal dialysis patients, respectively, in 2000. Pediatric hemodialysis patients received intravenous iron less frequently than adults (66.3% vs. 82.5% patient years; P < 0.0001). CONCLUSION: Hemoglobin values in rHuEPO-treated pediatric dialysis patients lagged behind those of adult patients, with pediatric patients achieving target hemoglobin values only a minority of the time (45.9% and 30.5% patient years, respectively, for hemodialysis and peritoneal dialysis). Trends show recent improvement in anemia treatment of children on dialysis. Still, further attention to and analysis of rHuEPO and iron therapy in pediatric dialysis patients is warranted.     

Clinical factors associated with achieving K/DOQI hemoglobin targets in hemodialysis patients

BACKGROUND: Few studies have assessed treatable factors associated with achieving the Kidney Disease Outcomes Quality Initiative (K/DOQI) guideline of hemoglobin values of 11 to 12 g/dL in anemic hemodialysis patients. METHODS: This was a retrospective study of 30,029 prevalent hemodialysis patients with mean hemoglobin values less than 11 g/dL between January 1 and March 31, 1999. We studied the associations between demographic characteristics, comorbid conditions, disease severity, urea reduction ratio, epoetin doses, intravenous iron doses, and mean hemoglobin values in the ensuing 3 months. RESULTS: Approximately half (51.3%) of patients reached a mean hemoglobin value of at least 11 g/dL. By multiple logistic regression, the major factors showing a positive association with this outcome included a urea reduction ratio greater than 75% (odds ratio [OR], 1.23; P < 0.0001) and intravenous iron (OR: for 0 vials/month, 1; for < 1, 1.22; for 1 to 1.9, 1.36; 2 to 2.9, 1.48; for 3 to 3.9, 1.61; for > or = 4, 1.79; P < 0.0001), while a negative association with hemoglobin response, possibly representing epoetin resistance, was shown for initial severity of anemia (OR: for initial hemoglobin value < 7 g/dL, 0.06; for 7 to 7.9 g/dL, 0.12; for 8 to 8.9 g/dL, 0.23; for 9 to 9.9 g/dL, 0.45; for 10 to 10.9 g/dL, 1; P < 0.0001) and epoetin doses in the highest quintile (OR for > 38,000 units/wk, 0.76; P < 0.0001). CONCLUSION: In patients with persistently low hemoglobin values, optimizing urea clearance and a proactive approach to intravenous iron therapy may enhance epoetin responsiveness.     

Hemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin

BACKGROUND: Treatment with recombinant human erythropoietin (rHuEPO) has been a major advance for the management of anemia in patients on hemodialysis. Therapy, however, is often observed to be associated with recurrent cyclic fluctuations in hemoglobin levels. The purpose of this analysis was to describe the phenomenology of hemoglobin cycling during rHuEPO treatment. METHODS: Data were analyzed for 281 hemodialysis patients treated at Winthrop-University Hospital Dialysis Centers between 1998 and 2003. Eligible patients' first full 1-year period with less than 10 hospital days was studied. Hemoglobin cycling (cycles with amplitude >1.5 g/dL and duration >8 weeks) and excursions (half of one full cycle) were analyzed. RESULTS: Greater than 90% of patients experienced hemoglobin cycling. The mean number of hemoglobin excursions was 3.1 +/- 1.1 per patient/year. The mean amplitude per hemoglobin excursion was 2.51 +/- 0.89 g/dL. The mean duration of hemoglobin excursions was 10.3 +/- 5.1 weeks. Factors associated with initiation of up excursions included increases in rHuEPO dose (84%), intravenous iron treatment initiation or increase in dose (27%), posthospital discharge (36%), factors associated with down excursions included rHuEPO dose hold (15%) or dose reduction (62%), infection (6%), discontinuation of intravenous iron therapy (5%), and hospitalization (14%). Patients with frequent hemoglobin cycling (>two full cycles per year) were characterized as being more responsive to rHuEPO [index of EPO responsiveness (ERI) 1036 +/- 659 compared to 1992 +/- 701 for other patients] (P = 0.02). CONCLUSION: Hemoglobin cycling is a common occurrence in rHuEPO-treated hemodialysis patients. It is most closely associated with frequent rHuEPO dose changes, hospitalization, and iron treatment practices.     

Possible influence of vitamin D receptor gene polymorphisms on recombinant human erythropoietin requirements in dialysis patients

BACKGROUND: Vitamin D receptor (VDR) gene polymorphisms have been widely studied, especially to analyze their effects on calcium-phosphorus metabolism and secondary hyperparathyroidism in patients on dialysis. In this study, we sought to investigate the possible effects of these polymorphisms on the anemia of renal failure and recombinant human erythropoietin (rHuEPO) responses among patients receiving hemodialysis. METHODS: One hundred twenty-eight patients (52 females/76 males) underwent genotyping for the insertion/deletion Bsml (B-->b, restriction site, exon VIII-->IX) and Tagl (T-->t, 352 exon IX) VDR gene polymorphisms. The mean value of the last 6 months' monthly evaluated laboratory values (C-reactive protein, hemoglobin, iron indices, PTH, and albumin) and clinical findings (rHuEPO requirement, cumulative iron supplementation doses, and body weight) were analyzed retrospectively excluding patients with chronic inflammation, hemolytic anemia, or active blood loss such as gastrointestinal bleeding. RESULTS: Mean age and dialysis durations were 41.5 +/- 11.8 years and 91.8 +/- 45.3 months, respectively. Polymorphism percentages were as follows: Bsml; BB/Bb/bb: 32.2/63.6/4.2 and Tagl; TT/Tt/tt: 40.5/55.4/4.1%, respectively. BB variant of Bsml gene was related to lower rHuEPO needs (P < .05) and also higher hemoglobin levels (P < .005) when compared with the Bb/bb variant. Considering Tagl variants, transferrin saturation levels were lower (P < .03) among patients with the Tt/tt variant, but there was no other significant difference in the mean values of other data between TT and Tt/tt variants. CONCLUSION: The BB variant of Bsml was related to decreased rHuEPO requirements to achieve higher hemoglobin levels among maintenance hemodialysis patients without chronic inflammation.     

Use of recombinant erythropoietin in thalassemic patients on dialysis.

We studied the therapeutic benefit of recombinant human erythropoietin (rHuEPO) in dialysis patients with thalassemia minor. Four of the 40 randomly selected patients (22 on hemodialysis [HD], 18 on continuous ambulatory peritoneal dialysis [CAPD]) were identified to be thalassemic prior to a trial of rHuEPO (alpha-thalassemia trait in three and beta-thalassemia minor in one). All patients were initially treated with rHuEPO at a dose of 100 +/- 25 U/kg/wk subcutaneously depending on the hemoglobin level. EPO injections were continued for 16 weeks with further adjustments of the doses according to the hemoglobin level increases attained. All nonthalassemic patients reached a target hemoglobin of 10 g/dL at week 16, with an average maintenance dose of 120 +/- 7.8 U/kg/wk, but the hemoglobin was increased by only 1 g/dL in the thalassemic patients receiving 175 U/kg/wk. Following cessation of rHuEPO therapy for 6 weeks, all four thalassemic patients and 18 randomly selected nonthalassemic patients received a fixed dose of rHuEPO 4,000 U/wk (equivalent to 80 U/kg/wk) for 16 weeks. The hemoglobin remained unchanged in the thalassemic patients, but a progressive and significant increase of hemoglobin was observed in the nonthalassemic patients. At the last phase of the study, the thalassemic patients received rHuEPO at a dose of 100 or 125 U/kg/wk with 4-weekly increments of 25 U/kg/wk until their hemoglobin reached 10 g/dL. One patient developed uncontrolled hypertension with a dose of 150 U/kg/wk, and one reached the target hemoglobin at a dose of 200 U/kg/wk.(ABSTRACT TRUNCATED AT 250 WORDS)     

Current concepts of anemia management in chronic renal failure: impact of NKF-DOQI

Since the introduction of recombinant human erythropoietin (rHuEPO) into clinical nephrology practice 10 years ago, there has been a slow increase in hemoglobin (Hgb) levels, but most patients with the anemia of chronic renal failure are still moderately anemic and have not achieved the target Hgb (11 to 12 g/dL) recommended by the NKF-DOQI anemia guidelines. Functional iron deficiency, insufficient rHuEPO doses and comorbid factors such as inflammation/infection have been the major reasons for not achieving this target. By optimizing iron stores with regular infusions of intravenous iron in the hemodialysis patient (who has significant blood [iron] losses related to the hemodialysis procedure), and giving adequate amounts of rHuEPO, preferably subcutaneously instead of intravenously, the NKF-DOQI recommended target Hb can be achieved in the majority of patients so treated.     

The effects of higher hemoglobin levels on mortality and hospitalization in hemodialysis patients

BACKGROUND: The introduction of recombinant human erythropoietin for the treatment of anemia of chronic renal failure provided the opportunity to correct anemia in this patient population. The optimal target hemoglobin for patients with end-stage renal disease (ESRD) remains controversial. A large database of hemodialysis patients was analyzed to determine whether increasing hemoglobin level above the current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) recommendations was associated with increased risk of mortality and hospitalization. METHODS: A longitudinal study of hemodialysis patients in Fresenius Medical Care-North America facilities was performed. Selection was restricted to patients in the census for 6 consecutive months from July 1, 1998 through June 30, 2000. Patient mean hemoglobin and other covariates measured during the initial 6 months were related to survival, number of hospitalizations, and length of stay over the subsequent 6 months of follow-up. RESULTS: Patients with hemoglobin <9 g/dL had an adjusted relative risk of death of 2.11 compared to those patients with 11 /=13 g/dL had an adjusted length of stay of 9.6 days compared to 10.9 days for those with 11 12 g/dL.     

Randomized trial of darbepoetin alfa for treatment of renal anemia at a reduced dose frequency compared with rHuEPO in dialysis patients

BACKGROUND: Darbepoetin alfa is a glycoprotein with a three-fold longer terminal half-life than recombinant human erythropoietin (rHuEPO). We aimed to determine whether darbepoetin alfa is as effective and well tolerated as rHuEPO for treating renal anemia in dialysis patients when administered at a reduced dose frequency. METHODS: A total of 522 European and Australian hemodialysis and peritoneal dialysis patients receiving stable rHuEPO therapy by either the intravenous (IV) or subcutaneous (SC) route were randomized, open-label in a 1:2 ratio to continue rHuEPO or to receive an equivalent dose of darbepoetin alfa at a reduced dose frequency. Patients receiving rHuEPO once weekly changed to once every other week darbepoetin alfa, and those receiving rHuEPO two or three times weekly changed to once-weekly darbepoetin alfa. The doses of rHuEPO and darbepoetin alfa were titrated to maintain hemoglobin close to the patient's baseline level for up to 52 weeks. The primary endpoint was the change in hemoglobin between baseline and the evaluation period at weeks 25 to 32 of treatment. RESULTS: The mean change in hemoglobin from baseline to the evaluation period was similar in the darbepoetin alfa (-0.03 g/dL; SE 0.11) and rHuEPO (-0.06 g/dL; SE 0.13) groups, and the difference between the two treatments was 0.03 g/dL (95% CI -0.16, 0.21). This was not a statistically significant or clinically relevant difference, despite the reduced frequency of darbepoetin alfa administration. At the end of the evaluation period, >/=95% of patients had their hemoglobin successfully maintained on their assigned dose frequency for darbepoetin alfa (once weekly and once every other week) and rHuEPO (once, twice and three times weekly). The safety profiles of darbepoetin alfa and rHuEPO were similar, and no antibodies to either treatment were detected. CONCLUSIONS: Darbepoetin alfa maintains hemoglobin as effectively as rHuEPO, but with a reduced dose frequency.     

Changes in anemia management and hemoglobin levels following revision of a bundling policy to incorporate recombinant human erythropoietin

In April 2006, Japan's health insurance system instituted a bundling policy that included recombinant human erythropoietin (rHuEPO) in outpatient hemodialysis therapy. To evaluate outcomes of this, we analyzed a prospective cohort of hemodialysis patients in the Japan Dialysis Outcomes and Practice Patterns Study, in 53 facilities using prevalent cross-sections of 1584 patients before and 1622 patients after the rHuEPO reimbursement change. Patient data included hemoglobin levels, iron management profiles, and anemia treatment with rHuEPO and intravenous iron. No significant differences were found in pre- or post-policy cross-sections for hemoglobin distributions or the percentage of patients prescribed rHuEPO. Among patients receiving rHuEPO, the mean dose significantly decreased by 11.8 percent. The percentage of patients prescribed intravenous iron over 4 months significantly increased; however, the mean dose of iron did not significantly change. Thus, this bundling policy was associated with reduced rHuEPO doses, increased intravenous iron use, and stable hemoglobin levels in Japanese patients receiving hemodialysis.     

Pilot study of the optimum hematocrit for patients in the predialysis stage after renal transplantation

Anemia is a common complication in patients with chronic kidney diseases including posttransplant patients. Guidelines for the treatment of anemia in chronic kidney disease published by NHF-K/DOQI recommend the target hemoglobin and hematocrit (Hb and Ht) levels to be in the 11 to 12 g/dL and 33% to 36% ranges, respectively, which are somewhat higher than those recommended in Japan (Ht = 30%). However, these guidelines were established mainly from the data on hemodialysis patients with only limited information available as to the impact of anemia control in posttransplant patients. The aim of the present study was to evaluate cardiac function and quality of life (QOL) when the Ht was raised to about 36% by administration of recombinant-human-erythropoietin (rHuEPO) to patients with mild impairment of renal function (s-Cre < 2.0 mg/dL) after renal transplantation. Twenty-five patients were analyzed for cardiac function, blood data, and QOL in a prospective study encompassing 8 months of rHuEPO treatment. Using a once weekly subcutaneous dose of 6000 IU of Epoetin-beta, the Ht became 33% to 36% and Hb was 11 to 12 g/dL. Among the cardiac function tests, left ventricular end-diastolic diameter and left ventricular mass index decreased significantly. QOL did not show any significant changes after administration of rHuEPO. In conclusion, we demonstrated a potential benefit of using rHuEPO to maintain the Hb between 11 and 12 g/dL and the Ht between 33% and 36% in posttransplant patients with regard to the prevention of cardiovascular complications. Further study is required to establish the benefits of correcting anemia by rHuEPO on the outcome of posttransplant patients.     

Novel erythropoiesis stimulating protein for treatment of anemia in chronic renal insufficiency

BACKGROUND: Novel erythropoiesis stimulating protein (NESP) is a glycoprotein with a threefold longer terminal half-life than recombinant human erythropoietin (rHuEPO) in humans. The aim of this study was to determine whether NESP is effective for the treatment of anemia at a reduced dosing frequency relative to rHuEPO in patients with chronic renal failure not yet on dialysis [chronic renal insufficiency (CRI)]. METHODS: This was a multicenter, randomized, open-label study. A total of 166 rHuEPO-naive patients with CRI were randomized in a 3:1 ratio to receive NESP (0.45 microg/kg once weekly) or rHuEPO (50 U/kg twice weekly) administered subcutaneously for up to 24 weeks. Dose adjustments were made as necessary to achieve a hemoglobin response, defined as an increase > or =1.0 g/dL from baseline and a concentration > or = 11.0 g/dL. RESULTS: During the 24-week treatment period, 93% (95% CI, 87 to 97%) of patients receiving NESP and 92% (95% CI, 78 to 98%) of patients receiving rHuEPO achieved a hemoglobin response. The median time to response was seven weeks (range of 3 to 25 weeks) in both groups. After correction of anemia, mean hemoglobin concentrations were maintained within the target range of 11.0 to 13.0 g/dL for the remainder of the 24-week treatment period. The safety profiles of NESP and rHuEPO were similar, and no antibodies were detected to either drug. CONCLUSIONS: These results demonstrate that NESP safely and effectively corrects and maintains hemoglobin concentrations at a reduced dosing frequency relative to rHuEPO in patients with CRI, providing a potential benefit to patients and health care providers.     

Access site-related infection in dialysis: the AStRID project: a multicenter prospective Italian study

A multicenter prospective study has been planned, in a large sample of Italian end-stage renal disease (ESRD) patients, aiming to assess the vascular access (VA) site-related infection rates and to identify variables associated with them. All ESRD patients undergoing chronic hemodialysis (HD) in the participating centers will be enrolled in the study. Participating centers were selected on a voluntary basis. Patients will be enrolled within an 18-month recruitment period. Primary study end points are the overall incidence rate of VA-related infections in ESRD patients on chronic HD (defined as infection episodes/100 patient-months), and the incidence rate of different types of VA-related infections (exit site, tunnel and bacteraemia/sepsis). All VA types in use will be evaluated: fistula, graft, tunneled (permanent) central venous catheter (CVC) and temporary CVC.     

Anemia in pediatric hemodialysis patients: results from the 2001 ESRD Clinical Performance Measures Project

BACKGROUND: Despite improvements in dialysis care, anemia remains a problem in pediatric hemodialysis patients. METHODS: To assess possible explanations for the anemia, clinical data were obtained from the Centers for Medicare and Medicaid Services on all hemodialysis patients ages 12 to <18 years between October and December 2000. Complete data were available for 435 of the 516 patients (84%). RESULTS: A total of 160 (37%) patients had a mean hemoglobin of <11 g/dL (anemic). The mean (+/- SD) age for these patients was 15.5 +/- 1.8 years compared to 15.9 +/- 1.5 years for the target hemoglobin patients (P < 0.05). Mean time on chronic dialysis was similar for both the anemic and target hemoglobin patients (>/=100 g/dL) ( approximately 3 years) but patients on dialysis <6 months were more likely to be anemic (67%). While nearly all patients were treated with erythropoietin, anemic patients received greater weekly erythropoietin doses (intravenous, anemia 374 +/- 232 units/kg/week vs. target hemoglobin 246 +/- 196 units/kg/week, P < 0.001; and subcutaneous, 304 +/- 238 units/kg/week vs. 167 +/- 99 units/kg/week, P < 0.05). A total of 59% of anemic patients had a mean transferrin saturation (TSAT) >/=20% compared to 71% of patients with a target hemoglobin (P < 0.01). A mean serum ferritin >/=100 ng/mL was present in approximately two thirds of the anemic and target hemoglobin patients. Approximately 60% of all children were treated with intravenous iron. The mean Kt/V values were lower for anemic patients (1.46 +/- 0.4 vs. 1.53 +/- 0.3, P < 0.05). Anemic patients were less likely to have a normal serum albumin (29% anemic vs. 52% target hemoglobin patients, P < 0.001). CONCLUSION: In the final multivariable regression model, dialyzing <6 months, a low albumin, and a mean TSAT <20% remained significant predictors of anemia in children.     

Hemoglobin variability in epoetin-treated hemodialysis patients

BACKGROUND: Understanding the clinical variability of hemoglobin measurements in epoetin-treated hemodialysis patients is important, particularly when this therapy is aimed at maintaining patient hemoglobin levels within a narrow range, such as the 11 to 12 g/dL range recommended in National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NKF-K/DOQI) guidelines. This study examines hemoglobin variability under conditions of standard clinical practice in epoetin-treated hemodialysis patients. METHODS: We studied 987 hemodialysis patients participating in an observational retrospective study that evaluated anemia management practices from October 1, 1996 to December 31, 1997 at 11 United States dialysis centers that were randomly selected from a pool of nearly all United States dialysis facilities. Each participating facility maintained its own anemia management protocols without specific anemia management recommendations or interventions made as part of this study. Hemoglobin variability was determined by calculating the 1-month and 2- to 6-month rolling average hemoglobin for each patient. The range of mean hemoglobin values that included the middle 50% (25th to 75th percentile), 80% (10th to 90th percentile), and 90% (5th to 95th percentile) of values were determined. The hemoglobin ranges that included 1 standard deviation (SD) (67%) of the study values and 2 SD (95%) of the study values for each time period were calculated. RESULTS: The mean hemoglobin was between 10.9 and 11.2 g/dL throughout the study. The hemoglobin range encompassing 50%, 80%, and 90% of values from a single month was 1.7, 3.3, and 4.4 g/dL, respectively. A progressive narrowing in the range of hemoglobin values encompassed by each percentile grouping (i.e., hemoglobin variability) was observed as longer rolling intervals were averaged. The hemoglobin range within the 25th to 75th percentile was 1.7 g/dL using single-month hemoglobin values and 1.1 g/dL using a 6-month rolling average. The range of hemoglobin values that encompassed 90% of patients was 4.4 g/dL using single-month values, 3.7 g/dL using 3-month rolling averages, and 3.2 g/dL using 6-month rolling averages. Fewer than 50% of patients had hemoglobin values within the 1.0 g/dL NKF-K/DOQI recommended range, even when a 6-month rolling average was applied. When hemoglobin values were measured for 1 month, 1 SD was 1.4 g/dL; for the 3-month rolling average, 1 SD was 1.1 g/dL; and for the 4-, 5-, and 6-month rolling averages, 1 SD was 1.0 g/dL. Greater hemoglobin variability correlated with higher mean corpuscular hemoglobin (P = 0.003) and serum ferritin (P = 0.047), and inversely correlated with age (P = 0.006) and serum albumin (P = 0.0001). CONCLUSION: Substantial variability occurs in hemoglobin values in epoetin-treated hemodialysis patients. The NKF-K/DOQI recommended hemoglobin range appears to be too narrow in clinical practice. Expanding the target range and use of rolling average hemoglobin intervals of 3 to 6 months as a clinical and quality assurance measure avoids clinical variability inherent with the use of isolated hemoglobin values or single-month hemoglobin averages.     

Additional effect of hyperparathyroidism on inflammatory status and rHuEPO requirements in hemodialysis patients

BACKGROUND: The aim of this study was to analyze the effects of elevated parathyroid hormone (iPTH) and C-reactive protein (CRP) on rHuEPO requirements and associated clinical and biochemical parameters of hemodialysis patients. METHODS: A total of 127 hemodialysis patients were included. Laboratory values from the previous 3 months (monthly measured CRP, iPTH, albumin, prealbumin, calcium, phosphorus, and hemoglobin) and clinical findings (rHuEPO requirements, iron supplements, Kt/V) were recorded retrospectively. Patients were subgrouped according to presence of hyperparathyroidism (mean iPTH > 350 pg/mL) and chronic inflammation (mean CRP > 8.5 mg/L) as group I (low iPTH, low CRP, n = 32), group II (high iPTH, low CRP, n = 32), group III (low iPTH, high CRP, n = 32), and group IV (high iPTH, high CRP, n = 31). RESULTS: We found that group IV had lowest hemoglobin (P < .0001, .0001, .01, respectively), albumin (P < .0001), prealbumin (P < .0001, .0001, .02, respectively), and highest rHuEPO requirements (P < .0001, .0001, .01, respectively) compared to other groups despite of similar iron indices. Group III also had lower albumin (P < .002, .0001, respectively), prealbumin (P < .001, .01, respectively), hemoglobin (P < .001, .005, respectively), but higher rHuEPO requirements (P < .01) compared to group I and group II. CONCLUSIONS: We propose that hyperparathyroidism increases rHuEPO requirements and aggravates the negative effects of chronic inflammation in hemodialysis patients.     

Hemoglobin predicts long-term survival in dialysis patients: a 15-year single-center longitudinal study and a correlation trend between prealbumin and hemoglobin

BACKGROUND: Dialysis patients have much higher mortality rates than the general population. Anemia is a common complication of uremia and a major contributor to morbidity and mortality in dialysis patients. The benefits of anemia correction using recombinant human erythropoietin (rHuEPO) are well established. Optimum hemoglobin level for dialysis patients remain controversial. We have investigated the association of enrollment hemoglobin with long-term survival in hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS: We enrolled 529 HD and 326 PD patients from 1987 and followed them to April 2003. Demographics, enrollment, and clinical and laboratory data were recorded. The Kaplan-Meier method was used to compute observed survival, and the multivariate Cox regression analysis was used to identify the independent predictors of mortality risk. RESULTS: Mean ages of HD and PD patients were 60 +/- 16 (SD) and 54 +/- 16 (SD) years, respectively. Forty-seven percent of HD patients and 41% of PD patients were diabetic. Mean enrollment hemoglobin levels of HD and PD patients were 9.44 +/- 1.9 and 9.61 +/- 1.77 g/dL respectively. Cumulative 15 year observed survivals of HD (P = 0.05) and PD (P = 0.032) patients with hemoglobin levels greater or equal to 12 g/dL were higher than those with hemoglobin levels less than 12 g/dL. Hemoglobin <12 g/dL was a better predictor of mortality in nondiabetics than diabetics, particularly in HD patients. Both in HD and PD diabetic patients, hemoglobin was not a significant predictor of mortality. By Cox regression analysis, after adjusting for age, race, gender, and months on dialysis at enrollment, the relative risk of mortality of patients with hemoglobin <12 g/dL was 2.13-fold (P = 0.008) higher for HD and 1.85-fold (P = 0.06) higher for PD compared to those with hemoglobin >/=12 g/dL (P = 0.035). A logistic regression analysis revealed a strong inverse relationship between the hemoglobin level and the odds risk of death in HD (OR = 0.83, P = 0.008) and in PD (OR = 0.85, P = 0.02) patients. CONCLUSION: Enrollment hemoglobin is a predictor of long-term survival in HD and PD patients. Patients with hemoglobin levels that are higher than current treatment recommendations (>12 g/dL) may benefit from long-term survival. Survival of dialysis patients may be improved by better management of malnutrition and anemia.     

Using cuffed and tunnelled central venous catheters as permanent vascular access for hemodialysis: a prospective study

BACKGROUND: Adequate care of a hemodialysis patient requires constant attention to the need to maintain vascular access (VA) patency. VA complications are the main cause of hospitalization in hemodialysis patients. The native arteriovenous fistula (NAVF), synthetic arteriovenous grafts fistula (GAVF) and silastic cuffed central venous catheters (CVCs) are used for permanent vascular access (PVA). CVCs are primary the method of choice for temporary access. But using this access modality is increasing more and more for PVA in elderly hemodialysis patients and when other PVA is not possible. The primary aim of this study is to investigate survivals and complications of the CVCs used for long-term VA. METHODS: We prospectively looked at 92 CVCs (Medcomp Ash Split Cath, 14 FR x 28 cm (Little, M.A.; O'Riordan, A.; Lucey, B.; Farrell, M.; Lee, M.; Conlon, P.J.; Walshe, J.J. A prospective study of complications associated with cuffed, tunnelled hemodialysis catheters. Nephrol. Dial. Transplant. 2001, 16 (11), 2194-2200) with Dacron cuff) inserted in 85 (50 females, 35 males) chronic hemodialysis patients (the mean age: 56.6 +/- 14.1 years) from July 1999 to January 2002. The overall survival and complications were followed up. Furthermore, the patients were evaluated for demographic and clinical characteristics. Data were analysed by chi-square, Wilcoxon rank and Kaplan-Meier survival tests. RESULTS: The median duration of CVC survival was 289 days (range: 10-720). Eleven (11.9%) CVCs were removed due to complications. In 79 (92.9%) patients, 1, in 5 (5.8%) patients, 2 and in 1 patient, 3 CVCs were inserted. Of the 85 patients, 56 have CVCs functioning. In addition, 27 (31.76%) patients have CVCs functioning for over 12 months, 17 (20%) patients have CVCs functioning for 6 months. The total incidence of CVC related infections was 0.82 episodes/1000 catheter days. Besides, thrombosis was occurred in 10 (10.8%) CVCs. The most frequent indications for CVC removal were patient death (69.4%), thrombosis (16.6%) and CVC-related infections (13.8%). CONCLUSIONS: CVCs are primarily used for temporary access. But this study indicates that CVC may be a very useful alternative permanent vascular access for hemodialysis patients when other forms of vascular access are not available.     

Improvement of brain function in hemodialysis patients treated with erythropoietin

To evaluate the effects of recombinant human erythropoietin (rHuEPO) on brain function, 15 chronic hemodialysis patients were studied by event-related P300, stimulus-related evoked potentials, and trailmaking before (hematocrit 22.7%) and after rHuEPO (hematocrit 30.6%). P300 peak latency elicited by a tone discrimination paradigm improved (391 before vs. 366 ms after; Cz = vertex; P less than 0.01) confirming beneficial effects on cerebral cognitive processing. P300 amplitude (13.6 vs. 15.8 microV; P = 0.06) and trailmaking tended to improve (55 vs. 43 s). P300 measures were influenced by low hemoglobin levels before rHuEPO (P less than 0.01), suggesting that severe anemia may contribute to uremic brain dysfunction. Furthermore, decrease of stimulus-related auditory brainstem I-V interpeak latency (4.28 before vs. 4.17 ms after; P less than 0.05) and increase of somatosensory N20/P25 amplitude (4.8 vs. 7.0 microV; P less than 0.05) pointed to improvement of sensory pathways by mechanisms unrelated to cognition. Brain dysfunction in chronic hemodialysis patients may, beside other factors, in part be caused by severe anemia and can be improved by rHuEPO treatment.     

Anemia, hospitalization, and mortality in patients receiving peritoneal dialysis in the United States

BACKGROUND: The view that hemoglobin levels in peritoneal dialysis patients should be maintained at 11 to 12 g/dL is based largely on the results of studies in hemodialysis patients. METHODS: We studied 13,974 erythropoietin-treated Medicare patients who initiated peritoneal dialysis between 1991 and 1998. Mean hemoglobin levels for the first 6 months of the study and, subsequently, time to first hospitalization and death during a 2-year follow-up were determined. RESULTS: The percentages of patients with hemoglobin levels of <10, 10 to 10.9, 11 to 11.9, and >/=12 g/dL were 24.6%, 40.6%, 27.6%, and 7.2%, respectively. First-hospitalization and death rates, respectively, were 109.5 and 21.6 per 100 patient-years in nondiabetic patients, and 152.9 and 31.5 in diabetic patients. In nondiabetic patients, adjusted hospitalization hazard ratios for hemoglobin levels of <10, 10 to 10.9, 11 to 11.9 (reference category), and >/=12 g/dL were 1.29 (P < 0.0001), 1.15 (P < 0.0001), 1, and 0.98 (NS), respectively. The corresponding adjusted mortality hazard ratios were 1.43 (P < 0.0001), 1.13 (P < 0.05), 1, and 1.14 (NS). In diabetic patients, hazard ratios of 1.26 (P < 0.0001), 1.07 (NS), 1, and 0.82 (P < 0.01) were observed for hospitalization, and 1.34 (P < 0.0001), 1.18 (P < 0.01), 1, and 0.92 (NS) for mortality. CONCLUSION: In peritoneal dialysis patients, anemia is associated with hospitalization and mortality in a manner supporting current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) hemoglobin targets. In addition, hemoglobin levels of >/=12 g/dL are associated with lower hospitalization rates in diabetic patients.     

The new rHuEPO alpha (epotin) in the management of anemia of end-stage renal disease in patients on maintenance hemodialysis

Recombinant human erythropoietin has proved to be effective to treat anemia of end-stage renal disease (ESRD). The aim of this study was to assess the efficacy and safety profile of Epotin, a rHuEPO produced in the Middle East. One hundred thirty patients with Hct 相似文献