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Anemia and Cardiovascular Disease, Hospitalization, End Stage Renal Disease, and Death in Older Patients with Chronic Kidney Disease

Abstract

Background: Large observational studies examining the association between anemia and “hard” clinical outcomes are rare in patients with chronic kidney disease (CKD).

Methods: We used the General Medicare 5% Denominator Files to identify patients aged 67 years or more with CKD on December 31, 1999. Outcomes in the ensuing 2 years were compared in patients with and those without anemia (entry period, 1998–1999; follow-up period, 2000–2001).

Results: Of 41,522 CKD patients identified, 49.0% had claims of anemia diagnosis. The factors associated (p< 0.0001) with anemia included older age, female gender, black race, and all 10 comorbid conditions studied; adjusted odds ratios (ORs) exceeded 1.5 for age 80 years old or older (OR, 1.54 compared to <70 years), for black race (OR, 1.52), and for co-existing diagnoses of congestive heart failure (OR, 1.64), gastrointestinal bleeding (OR, 3.65), and liver disease (OR, 2.16). During the follow-up period, outcome event rates (expressed per 1000 patient-years) were as follows: renal replacement therapy, 23.5; death, 186.4; congestive heart failure, 390.0; atherosclerotic vascular disease, 410.5; and first hospitalization, 552.6. Using proportional hazards modeling, the presence of anemia was associated (p < 0.0001) with the following adjusted hazards ratios: atherosclerotic vascular disease, 1.09; congestive heart failure, 1.14; renal replacement therapy, 2.61 and death, 1.40. Conclusion: A diagnosis of anemia is present in nearly half of all patients with CKD, aged 67 years or more, a group at very high risk of cardiovascular disease, hospitalization, end-stage renal disease, and death. Anemia is associated with each of these events.

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References

  1. 1.

    InstitutionalAuthorNameNational Kidney Foundation-Dialysis Outcomes Quality Initiative. (1997) ArticleTitleNKF-DOQI clinical practice guidelines for the treatment of anemia of chronic renal failure Am J Kidney Dis 30 S192–S240

  2. 2.

    F Madore E Lowrie C Brugnara et al. (1997) ArticleTitleAnemia in hemodialysis patients: Variables affecting this outcome predictor J Am Soc Nephrol 8 IssueID12 1921–1929 Occurrence Handle9402095

  3. 3.

    H Xia J Ebben J Ma A. Collins (1999) ArticleTitleHematocrit levels and hospitalization risks in hemodialysis patients J Am Soc Nephrol 10 1309–1316 Occurrence Handle10361870

  4. 4.

    AJ Collins S Li WL St Peter et al. (2001) ArticleTitleDeath, hospitalization, and economic associations among incident hemodialysis patients with hematocrit values of 36 to 39% J Am Soc Nephrol 12 2465–2473 Occurrence Handle11675424

  5. 5.

    LP McMahon JA Johns A McKenzie et al. (1992) ArticleTitleHaemodynamic changes and physical performance at comparative levels of haemoglobin after long-term treatment with recombinant erythropoietin Nephrol Dial Transplant 7 1199–1206 Occurrence Handle1337160

  6. 6.

    A Sikole M Polenakovic V Spirovska et al. (1993) ArticleTitleAnalysis of heart morphology and function following erythropoietin treatment of anemic dialysis patients Artif Organs 17 977–984 Occurrence Handle8110072

  7. 7.

    RW Evans B Rader DL Manninen (1990) ArticleTitleThe quality of life of hemodialysis recipients treated with recombinant human erythropoietin JAMA 263 825–830 Occurrence Handle10.1001/jama.263.6.825 Occurrence Handle2404150

  8. 8.

    InstitutionalAuthorNameCanadian Erythropoietin Study Group (1990) ArticleTitleAssociation between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis BMJ 300 573–578

  9. 9.

    ST Lillevang FB. Pedersen (1990) ArticleTitleQuality of life of hemodialysis patients before and after erythropoietin therapy. A double-blind, randomized, placebo controlled study Ugeskr Laeger 152 2999–3002 Occurrence Handle2238169

  10. 10.

    InstitutionalAuthorNameThe US Recombinant Human Erythropoietin Predialysis Study Group. (1991) ArticleTitleDouble-blind, placebo-controlled study of the therapeutic use of recombinant human erythropoietin for anemia associated with chronic renal failure in predialysis patients Am J Kidney Dis 18 50–59

  11. 11.

    LP McMahon JK. Dawborn (1992) ArticleTitleSubjective quality of life assessment in hemodialysis patients at different levels of hemoglobin following use of recombinant human erythropoietin Am J Nephrol 12 162–169 Occurrence Handle1415377

  12. 12.

    RN Foley PS Parfrey J Morgan et al. (2000) ArticleTitleEffect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy Kidney Int 58 1325–1335 Occurrence Handle10.1046/j.1523-1755.2000.00289.x Occurrence Handle10972697

  13. 13.

    PH Chaves B Ashar JM Guralnik LP. Fried (2002) ArticleTitleLooking at the relationship between hemoglobin concentration and prevalent mobility difficulty in older women . Should the criteria currently used to define anemia in older people be reevaluated? J Am Geriatr Soc 50 1257–1264 Occurrence Handle10.1046/j.1532-5415.2002.50313.x Occurrence Handle12133021

  14. 14.

    MJ Sarnak H Tighiouart G Manjunath et al. (2002) ArticleTitleAnemia as a risk factor for cardiovascular disease in The Atherosclerosis Risk in Communities (ARIC) study J Am Coll Cardiol 40 27–33 Occurrence Handle10.1016/S0735-1097(02)01938-1 Occurrence Handle12103252

  15. 15.

    TB Horwich GC Fonarow MA Hamilton et al. (2002) ArticleTitleAnemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure J Am Coll Cardiol 39 IssueID11 1780–1786 Occurrence Handle10.1016/S0735-1097(02)01854-5 Occurrence Handle12039491

  16. 16.

    WM McClellan WD Flanders RD Langston et al. (2002) ArticleTitleAnemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study J Am Soc Nephrol 13 IssueID7 1928–1936 Occurrence Handle10.1097/01.ASN.0000018409.45834.FA Occurrence Handle12089390

  17. 17.

    M Kosiborod GL Smith MJ Radford et al. (2003) ArticleTitleThe prognostic importance of anemia in patients with heart failure Am J Med 114 112–119 Occurrence Handle10.1016/S0002-9343(02)01498-5 Occurrence Handle12586230

  18. 18.

    H Tanner G Moschovitis GM Kuster et al. (2002) ArticleTitleThe prevalence of anemia in chronic heart failure Int J Cardiol 86 115–121 Occurrence Handle10.1016/S0167-5273(02)00273-5 Occurrence Handle12400591

  19. 19.

    JA Ezekowitz FA McAlister PW. Armstrong (2003) ArticleTitleAnemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12,065 patients with new-onset heart failure Circulation 107 223–225 Occurrence Handle10.1161/01.CIR.0000052622.51963.FC Occurrence Handle12538418

  20. 20.

    AS Androne SD Katz L Lund et al. (2003) ArticleTitleHemodilution is common in patients with advanced heart failure Circulation 107 226–229 Occurrence Handle10.1161/01.CIR.0000052623.16194.80 Occurrence Handle12538419

  21. 21.

    DM Mancini SD Katz CC Lang et al. (2003) ArticleTitleEffect of erythropoietin on exercise capacity in patients with moderate to severe chronic heart failure Circulation 107 294–299 Occurrence Handle10.1161/01.CIR.0000044914.42696.6A Occurrence Handle12538431

  22. 22.

    DS Silverberg D Wexler M Blum et al. (2000) ArticleTitleThe use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations J Am Coll Cardiol 35 1737–1744 Occurrence Handle10.1016/S0735-1097(00)00613-6 Occurrence Handle10841219

  23. 23.

    DS Silverberg D Wexler D Sheps et al. (2001) ArticleTitleThe effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study J Am Coll Cardiol 37 1775–1780 Occurrence Handle10.1016/S0735-1097(01)01248-7 Occurrence Handle11401110

  24. 24.

    BC Astor P Muntner A Levin et al. (2002) ArticleTitleAssociation of kidney function with anemia: the Third National Health and Nutrition Examination Survey (1988–1994) Arch Intern Med 162 1401–1408 Occurrence Handle10.1001/archinte.162.12.1401 Occurrence Handle12076240

  25. 25.

    KS Kleinman SU Schweitzer ST Perdue et al. (1989) ArticleTitleThe use of recombinant human erythropoietin in the correction of anemia in predialysis patients and its effect on renal function: a double-blind, placebo-controlled trial Am J Kidney Dis 14 486–495 Occurrence Handle2688405

  26. 26.

    DA Revicki RE Brown DH Feeny et al. (1995) ArticleTitleHealth-related quality of life associated with recombinant human erythropoietin therapy for predialysis chronic renal disease patients Am J Kidney Dis 25 548–554 Occurrence Handle7702049

  27. 27.

    A Levin J Singer CR Thompson et al. (1996) ArticleTitlePrevalent left ventricular hypertrophy in the predialysis population: identifying opportunities for intervention Am J Kidney Dis 27 347–354 Occurrence Handle8604703

  28. 28.

    A Levin CR Thompson J Ethier et al. (1999) ArticleTitleLeft ventricular mass index increase in early renal disease: impact of decline in hemoglobin Am J Kidney Dis 34 125–134 Occurrence Handle10401026

  29. 29.

    DC Holland M. Lam (2000) ArticleTitlePredictors of hospitalization and death among pre-dialysis patients: a retrospective cohort study Nephrol Dial Transplant 15 650–658 Occurrence Handle10.1093/ndt/15.5.650 Occurrence Handle10809806

  30. 30.

    PL Hebert LS Geiss EF Tierney et al. (1999) ArticleTitleIdentifying persons with diabetes using Medicare claims data Am J Med Qual 14 270–277 Occurrence Handle10624032

  31. 31.

    M Duke WH. Abelmann (1969) ArticleTitleThe hemodynamic response to chronic anemia Circulation 39 503–515 Occurrence Handle5778251

  32. 32.

    AM. Katz (1994) ArticleTitleThe cardiomyopathy of overload: an unnatural growth response in the hypertrophied heart Ann Intern Med 121 363–371 Occurrence Handle8042826

  33. 33.

    JJ Hunter KR. Chien (1999) ArticleTitleSignaling pathways for cardiac hypertrophy and failure N Engl J Med 341 1276–1283 Occurrence Handle10.1056/NEJM199910213411706 Occurrence Handle10528039

  34. 34.

    C Kitiyakara J Gonin Z Massy CS. Wilcox (2000) ArticleTitleNon-traditional cardiovascular disease risk factors in end-stage renal disease: oxidate stress and hyperhomocysteinemia Curr Opin Nephrol Hypertens 9 477–487 Occurrence Handle10.1097/00041552-200009000-00004 Occurrence Handle10990365

  35. 35.

    T Grune O Sommerburg WG. Siems (2000) ArticleTitleOxidative stress in anemia Clin Nephrol 53 S18–S22 Occurrence Handle10746801

  36. 36.

    J Rossert B Fouqueray JJ. Boffa (2003) ArticleTitleAnemia management and the delay of chronic renal failure progression J Am Soc Nephrol 14 173–177S Occurrence Handle10.1097/01.ASN.0000070079.54912.B6

  37. 37.

    M Tepel GM der Particlevan M Statz et al. (2003) ArticleTitleThe antioxidant acetylcysteine reduces cardiovascular events in patients with end-stage renal failure: a randomized, controlled trial Circulation 107 992–995 Occurrence Handle10.1161/01.CIR.0000050628.11305.30 Occurrence Handle12600912

  38. 38.

    M Boaz S Smetana T Weinstein et al. (2000) ArticleTitleSecondary prevention with antioxidants of cardiovascular disease in endstage renal disease (SPACE): randomised placebo-controlled trial Lancet 356 1213–1218 Occurrence Handle10.1016/S0140-6736(00)02783-5 Occurrence Handle11072938

  39. 39.

    D Roth RD Smith G Schulman et al. (1994) ArticleTitleEffects of recombinant human erythropoietin on renal function in chronic renal failure predialysis patients Am J Kidney Dis 24 777–784 Occurrence Handle7977319

  40. 40.

    S Kuriyama H Tomonari H Yoshida et al. (1997) ArticleTitleReversal of anemia by erythropoietin therapy retards the progression of chronic renal failure, especially in nondiabetic patients Nephron 77 176–185 Occurrence Handle9346384

  41. 41.

    J Coresh BC Astor T Greene et al. (2003) ArticleTitlePrevalence of chronic kidney disease and decreased kidney function in the adult␣US population: Third National Health and Nutrition Examination Survey Am J Kidney Dis 41 1–12 Occurrence Handle10.1053/ajkd.2003.50007 Occurrence Handle12500213

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Correspondence to Robert N. Foley.

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Li, S., Foley, R.N. & Collins, A.J. Anemia and Cardiovascular Disease, Hospitalization, End Stage Renal Disease, and Death in Older Patients with Chronic Kidney Disease. Int Urol Nephrol 37, 395–402 (2005). https://doi.org/10.1007/s11255-004-3068-2

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Keywords:

  • Anemia
  • Chronic kidney disease
  • Medicare
  • Outcomes