Low- Versus Mid-Hematocrit Strategy for Dialysis Patients with Complex Conditions

A simulated randomized trial suggests similar outcomes with two common strategies for anemia management in elderly dialysis patients with multiple chronic conditions, reports Medical Care.

The researchers used data from the U.S Renal Data System to emulate a randomized comparative effectiveness trial of two hematocrit target strategies for older adults receiving dialysis who had serious comorbidities. The study compared a “low” hematocrit target of 30.0 to 34.5 percent and a “mid” target of 34.5 to 39.0 percent. The analysis included 22,474 dialysis patients, aged 65 or older, who had both diabetes and cardiovascular disease and who started dialysis between 2006 and 2008.

The analysis used follow-up data from 3 to 9 months after the patients started hemodialysis, including the “observational analogs” of intention-to-treat and per-protocol analyses. The models included inverse-probability weighting to adjust for time-dependent confounding by indication. All-cause mortality and a composite of mortality and cardiovascular events were compared between strategies.

The models found no significant differences between the mid- versus the low-hematocrit strategies. On both intention-to-treat and per-protocol analyses, hazard ratios were nonsignificant for all-cause mortality and for the composite outcome. There was also no evidence of benefit on analysis of patients with hematocrit greater than 30 percent at baseline, of those with serum albumin less than 3.5 g/dL, and excluding those with a poor response to epoietin.

Randomized trials have found that anemia management strategies targeting near-normal hematocrit levels (>39.0 percent) may lead to increased cardiovascular risk and mortality. By contrast, few studies have examined the outcomes of the most widely used hematocrit target of 34.5 to 39.0 percent.

The new analysis finds no difference in outcomes with the low- and mid-hematocrit targets studied, among elderly dialysis patients with multiple chronic conditions. The findings support recent advisories recommending a hematocrit target of less than 33 percent in treating hemodialysis patients, including those with major comorbid conditions [Zhang Y, et al. Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients. Med Care 2014; 52(Suppl 3):S132–S139].