Greater Epoetin alfa (EPO) doses and short-term mortality risk among hemodialysis patients with hemoglobin levels less than 11 g/dL
Greater Epoetin alfa (EPO) doses and short-term mortality risk among hemodialysis patients with hemoglobin levels less than 11 g/dL
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DOI：
10.1002/pds.1799
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发表时间：
2009-10-01
影响因子：
2.6
通讯作者：
Brookhart, M. Alan
中科院分区：
文献类型：
--
作者：
Bradbury, Brian D.;Do, Thy P.;Brookhart, M. Alan
目的我们研究了高剂量的EPO（用于提高血液透析患者的血红蛋白（Hb）水平并将其维持在目标范围内）与高剂量的EPO之间的关系，和短期死亡风险使用多变量回归和工具变量（IV）方法：我们确定了2000年7月至2010年3月期间在美国一家大型透析提供商的786个设施中接受血液透析的32734名患者2002年的患者接受了>4个月的连续护理，并且在第三个月时Hb < 11 g/dL。我们评估了Hb <11 g/dL后的剂量滴定，并基于剂量滴定> 25%（仪器）的患者百分比表征了设施。我们评估了在随后的90天内死亡，并评估了EPO剂量与死亡率的关系，采用传统的线性和IV regression.Results研究人群的平均（SD）年龄为60.4（15.0）岁; 48%是白色，42%是黑色和51%是男性。在未校正的分析中，高剂量EPO与90天死亡风险相关（风险差异，RD = 3.0/100人，95%CI：2.3-3.6）;校正混杂因素后死亡风险降低（RD = 1.5/100人，95%CI：0.8-2.2），在合并的IV分析中与高EPO剂量无关，尽管置信区间（CI）较宽（RD = -0.4/100人，95%CI：结论调整后的线性回归和IV回归之间的风险估计差异表明，短-与EPO给药相关的长期死亡率可能主要归因于较高剂量适应症的混淆。IV方法用于解决残留混杂的可能性，产生了接近零但不精确的效应估计值。版权所有（C）2009约翰威利父子有限公司
Purpose We examined the association between high doses of Epoetin alfa (EPO), which are used to raise and maintain hemoglobin (Hb) levels within target ranges for hemodialysis patients, and short-term mortality risk using multivariable regression and an instrumental variable (IV) analysis.Methods We identified 32 734 patients receiving hemodialysis in 786 facilities from a large US dialysis provider between July 2000 and March 2002 who received care for >4 consecutive months, and had an Hb < 11 g/dL in the third month. We assessed dose titrations following the Hb < I I g/dL and characterized facilities based on the percentage of patients with dose titrations > 25% (instrument). We assessed deaths during the subsequent 90 days and evaluated the EPO dose-mortality association using conventional linear and IV regression.Results The study population had a mean (SD) age of 60.4 (15.0) years; 48% were white, 42% were black and 51% were male. In unadjusted analyses, high EPO doses were associated with 90-day mortality risk (Risk Difference, RD = 3.0 per 100 persons, 95%CI:2.3-3.6); mortality risk was attenuated after adjustment for confounding (RD = 1.5 per 100 persons, 95%CI:0.8-2.2) and not associated with high EPO dose in the pooled IV analysis, though confidence intervals (CI) were wide (RD = -0.4 per 100 persons, 95%CI:-3.2-2.4).Conclusions The difference in risk estimates between the adjusted linear regression and the IV regression suggests that the short-term mortality related to EPO dosing may be largely attributable to confounding-by-indication for higher doses. The IV method, which was employed to address the possibility of residual confounding, yielded near null though imprecise effect estimates. Copyright (C) 2009 John Wiley & Sons, Ltd.