Keywords
Hospitalization
Mortality
Hemodialysis
Risk factor
How to Cite
Abstract
Background: Patients with chronic kidney disease (CKD) in hemodialysis have a higher hospitalization and mortality rate than the general population; therefore, studying the contribution of different risk factors is a priority. Hemoglobin alteration is common in CKD and is related to cardiovascular complications, which are the leading cause of death. However, there is no consensus on the appropriate hemoglobin values for CKD.
Purpose: To determine if altered hemoglobin levels are related to hospitalization and mortality in patients with CKD on hemodialysis.
Methodology: Observational retrospective cohort study that included 214 patients who started hemodialysis between 2019 and 2022. Hemoglobin levels at the start of hemodialysis were classified as altered (?10 and/or >12 g/dL) or reference (>10 to 12 g/dL) and were correlated with hospitalization and mortality using bivariate analysis with the Pearson chi-square test and multivariate analysis with the Cox regression model, with a significance level of p<0.05.
Results: A total of 214 CKD patients on hemodialysis were included in the study. Among them, 55 (48.2%) patients with altered hemoglobin were hospitalized, compared to 16 (16.0%) with reference hemoglobin (p<0.001). Additionally, 41 (36.0%) patients with altered hemoglobin died, compared to 5 (5.0%) with reference hemoglobin (p<0.001). In the remaining patients, no hospitalizations or mortality were reported during the course of the study. The relative risk of hospitalization for patients with altered hemoglobin was 3.02 (95% CI: 1.85-4.91), and the relative risk of mortality for patients with altered hemoglobin was 7.19 (95% CI: 2.96-17.49). In the multivariate analysis, altered hemoglobin, hypoalbuminemia, and hyperphosphatemia were associated with a higher mortality and hospitalization risk.
Conclusions: Altered hemoglobin increases the risk of hospitalization and mortality in hemodialysis patients.
References
Kidney Disease Improving Global Outcomes. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl. 2013;3(1):5-14.
Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382(9888):260-72. https://doi.org/10.1016/s0140-6736(13)60687-x
Bello AK, Okpechi IG, Osman MA, Cho Y, Htay H, Jha V, et al. Epidemiology of haemodialysis outcomes. Nat Rev Nephrol. 2022;18(6):378-95. https://doi.org/10.1038/s41581-022-00542-7
Gotta V, Tancev G, Marsenic O, Vogt JE, Pfister M. Identifying key predictors of mortality in young patients on chronic haemodialysis-a machine learning approach. Nephrol Dial Transplant. 2021;36(3):519-28. https://doi.org/10.1093/ndt/gfaa128
Lee HJ, Son YJ. Prevalence and associated factors of frailty and mortality in patients with end-stage renal disease undergoing hemodialysis: a systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(7):3471. https://doi.org/10.3390/ijerph18073471
Pan W, Han Y, Hu H, He Y. Association between hemoglobin and chronic kidney disease progression: a secondary analysis of a prospective cohort study in Japanese patients. BMC Nephrol. 2022;23(1):295. https://doi.org/10.1186/s12882-022-02920-6
Pérez Escobar MM, Herrera Cruz N, Pérez Escobar E. Comportamiento de la mortalidad del adulto en hemodiálisis crónica. Rev Arch Med Camagüey. 2017;21(1):773-86.
Kuo KL, Hung SC, Tseng WC, Tsai MT, Liu JS, Lin MH, et al. Association of anemia and iron parameters with mortality among patients undergoing prevalent hemodialysis in Taiwan: the AIM?HD study. J Am Heart Assoc. 2018;7(15):e009206. https://doi.org/10.1161/jaha.118.009206
Young EW, Wang D, Kapke A, Pearson J, Turenne M, Robinson BM, et al. Hemoglobin and clinical outcomes in hemodialysis: an analysis of US Medicare data from 2018 to 2020. Kidney Med. 2022;5(2):100578. https://doi.org/10.1016/j.xkme.2022.100578
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7(1):1-59. https://doi.org/10.1016/j.kisu.2017.04.001
Toft G, Heide-Jørgensen U, van Haalen H, James G, Hedman K, Birn H, et al. Anemia and clinical outcomes in patients with non-dialysis dependent or dialysis dependent severe chronic kidney disease: a Danish population-based study. J Nephrol. 2020;33(1):147-56. https://doi.org/10.1007/s40620-019-00652-9
Umboh O, Moies ES, Palar S. The effect of anemia and hypoalbuminemia on six-months hospitalization risk in end stage chronic kidney disease patients undergoing hemodialysis: a retrospective cohort study. Acta Med Indones. 2023;55(2):136-41.
Loaiza-Huallpa J, Condori-Huaraka M, Quispe-Rodríguez GH, Pinares-Valderrama MP, Cruz-Huanca AI, Atamari-Anahui N, et al. Mortalidad y factores asociados en pacientes con enfermedad renal crónica en hemodiálisis en un hospital peruano. Rev Haban Cienc Méd. 2019;18(1):164-75.
Alberto Casas B, Sosa Montenegro MF. Nivel de hemoglobina en relación a la mortalidad en pacientes con enfermedad renal crónica terminal en hemodiálisis [tesis de pregrado, Universidad Católica Santo Toribio De Mogrovejo, Chiclayo, Perú]. Repositorio de Tesis USAT; 2021. http://hdl.handle.net/20.500.12423/3326
Kido R, Akizawa T, Fukuhara S. Haemoglobin concentration and survival of haemodialysis patients before and after experiencing cardiovascular disease: a cohort study from Japanese dialysis outcomes and practice pattern study. BMJ Open. 2019;9(9):e031476. https://doi.org/10.1136/bmjopen-2019-031476
Song YH, Cai GY, Xiao YF, Chen XM. Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis. BMC Nephrol. 2020;21(1):377. https://doi.org/10.1186/s12882-020-02026-x
Fuller DS, Dluzniewski PJ, Cooper K, Bradbury BD, Robinson BM, Tentori F. Combinations of mineral and bone disorder markers and risk of death and hospitalizations in the International Dialysis Outcomes and Practice Patterns Study. Clin Kidney J. 2019;13(6):1056-62. https://doi.org/10.1093/ckj/sfz112
Soohoo M, Feng M, Obi Y, Streja E, Rhee CM, Lau WL, et al. Changes in markers of mineral and bone disorders and mortality in incident hemodialysis patients. Am J Nephrol. 2016;43(2):85-96. https://doi.org/10.1159/000444890
Li D, Liu W, Huang H, Guo W, Diao Z, Chen X, et al. Association between the risk of death and serum calcium, phosphate, and intact parathyroid hormone levels in older patients undergoing maintenance hemodialysis: a cohort study in Beijing. Ther Adv Endocrinol Metab. 2021;12:20420188211025161. https://doi.org/10.1177/20420188211025161
Song KK, Zhao DL, Wang YD, Wang Y, Sun XF, Miao LN, et al. Analysis of factors associated with death in maintenance hemodialysis patients: a multicenter study in China. Chin Med J. 2017;130(8):885-91. https://doi.org/10.4103/0366-6999.204103
Wang J, Streja E, Soohoo M, Chen JLT, Rhee CM, Kim T, et al. Concurrence of serum creatinine and albumin with lower risk for death in twice-weekly hemodialysis patients. J Ren Nutr. 2017;27(1):26-36. https://doi.org/10.1053/j.jrn.2016.07.001
Uludag K, Boz G, Gunal AI. Lower serum albumin level is associated with increased risk of hospital admission and length of stay in hospital among incident hemodialysis patients by using overdispersed model. Ther Apher Dial. 2021;25(2):179-87. https://doi.org/10.1111/1744-9987.13552
Natoli JL, Boer R, Nathanson BH, Miller RM, Chiroli S, Goodman WG, et al. Is there an association between elevated or low serum levels of phosphorus, parathyroid hormone, and calcium and mortality in patients with end stage renal disease? A meta-analysis. BMC Nephrol. 2013;14:88. https://doi.org/10.1186/1471-2369-14-88
Zhou X, Guo Y, Luo Y. The optimal range of serum intact parathyroid hormone for a lower risk of mortality in the incident hemodialysis patients. Ren Fail. 2021;43(1):599-605. https://doi.org/10.1080/0886022x.2021.1903927
Kim Y, Yoo KD, Kim HJ, Koh J, Yu Y, Kwon YJ, et al. Association of serum mineral parameters with mortality in hemodialysis patients: data from the Korean end-stage renal disease registry. Kidney Res Clin Pract. 2018;37(3):266-76. https://doi.org/10.23876/j.krcp.2018.37.3.266
Park JY, Yoo KD, Kim YC, Kim DK, Joo KW, Kang SW, et al. Early dialysis initiation does not improve clinical outcomes in elderly end-stage renal disease patients: a multicenter prospective cohort study. PLoS One. 2017;12(4):e0175830. https://doi.org/10.1371/journal.pone.0175830
Liu Y, Wang L, Han X, Wang Y, Sun X, Jiang H, et al. The profile of timing dialysis initiation in patients with end-stage renal disease in China: a cohort study. Kidney Blood Press Res. 2020;45(2):180-93. https://doi.org/10.1159/000504671
Jia X, Tang X, Li Y, Xu D, Moreira P. Update of dialysis initiation timing in end stage kidney disease patients: is it a resolved question? A systematic literature review. BMC Nephrol. 2023;24(1):162. https://doi.org/10.1186/s12882-023-03184-4
Fu EL, Evans M, Carrero JJ, Putter H, Clase CM, Caskey FJ, et al. Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study. BMJ. 2021;375:e066306. https://doi.org/10.1136/bmj-2021-066306
Escoli R, Luz I, Santos P, Vila Lobos A. Glomerular filtration rate and initiation of dialysis: dialysis initiation and GFR. Ther Apher Dial. 2017;21(6):606-10. https://doi.org/10.1111/1744-9987.12582
Park JY, Kim MH, Han SS, Cho H, Kim H, Ryu DR, et al. Recalibration and validation of the Charlson Comorbidity Index in Korean incident hemodialysis patients. PLoS One. 2015;10(5):e0127240. https://doi.org/10.1371/journal.pone.0127240
Chae JW, Song CS, Kim H, Lee KB, Seo BS, Kim DI. Prediction of mortality in patients undergoing maintenance hemodialysis by Charlson Comorbidity Index using ICD-10 database. Nephron Clin Pract. 2011;117(4):379-84. https://doi.org/10.1159/000321525
Lin Y, Yang C, Chu H, Wu J, Lin K, Shi Y, et al. Association between the Charlson Comorbidity Index and the risk of 30-day unplanned readmission in patients receiving maintenance dialysis. BMC Nephrol. 2019;20(1):363. https://doi.org/10.1186/s12882-019-1538-0
Zavacka M, Zelko A, Madarasova Geckova A, Majernikova M, Pobehova J, Zavacky P. Vascular access as a survival factor for the hemodialysis population: a retrospective study. Int Angiol. 2020;39(6):525-31. https://doi.org/10.23736/s0392-9590.20.04401-6
Ko GJ, Rhee CM, Obi Y, Chang TI, Soohoo M, Kim TW, et al. Vascular access placement and mortality in elderly incident hemodialysis patients. Nephrol Dial Transplant. 2020;35(3):503-11. https://doi.org/10.1093/ndt/gfy254
Yeh LM, Chiu SYH, Lai PC. The impact of vascular access types on hemodialysis patient long-term survival. Sci Rep. 2019;9:10708. https://doi.org/10.1038/s41598-019-47065-z
Kim HY, Bae EH, Ma SK, Kim SW. Association between initial vascular access and survival in hemodialysis according to age. Korean J Intern Med. 2019;34(4):867-76. https://doi.org/10.3904/kjim.2017.025
Okazaki M, Obi Y, Shafi T, Rhee CM, Kovesdy CP, Kalantar-Zadeh K. Residual kidney function and cause-specific mortality among incident hemodialysis patients. Kidney Int Rep. 2023;8(10):1989-2000. https://doi.org/10.1016/j.ekir.2023.07.020
Brener ZZ, Thijssen S, Kotanko P, Kuhlmann MK, Bergman M, Winchester JF, et al. The impact of residual renal function on hospitalization and mortality in incident hemodialysis patients. Blood Purif. 2011;31(4):243-51. https://doi.org/10.1159/000322252
Obi Y, Streja E, Rhee CM, Ravel V, Amin AN, Cupisti A, et al. Incremental hemodialysis, residual kidney function, and mortality risk in incident dialysis patients: a cohort study. Am J Kidney Dis. 2016;68(2):256-65. https://doi.org/10.1053/j.ajkd.2016.01.008
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