SP340IS LOW HEMOGLOBIN AT HEMODIALYSIS INITIATION ASSOCIATED WITH FIRST-YEAR SURVIVAL AMONG PATIENTS TREATED TO TARGET LEVELS SOON AFTER DIALYSIS START?

INTRODUCTION AND AIMS: Many patients initiate hemodialysis (HD) with low hemoglobin (Hgb) levels and receive intense therapy during the early HD period to achieve Hgb targets. Management of anemia before the start of HD may improve survival after dialysis start by avoiding the potential lingering harm of chronic anemia and/or avoiding high doses of ESA and IV iron in the early months of HD. To test this hypothesis, we investigated the association between low vs. target Hgb at HD start and mortality through 1 year of HD among patients with target Hgb at 4 months. METHODS: We analyzed incident HD patients from 21 countries in phases 4-5 (2009-2015) of the Dialysis Outcomes and Practice Patterns Study (DOPPS). Cox regression was used to estimate the association between Hgb measured within 30 days (month 1) of starting HD and mortality from month 4 through month 12 among patients with Hgb ≥ 10 g/dL at month 4. Models were stratified by DOPPS phase and country and adjusted for potential confounders. IV iron and ESA dose over the first 90 days of HD were added to the model in a sensitivity analysis because these factors may be on the causal pathway between low month 1 Hgb and death after month 4. RESULTS: The study population consisted of 4461 HD patients with Hgb ≥ 10 g/dL at month 4; at month 1, 80% had Hgb < 11 g/dL and 53% had Hgb < 10 g/dL. Compared to patients with Hgb <11 g/dL, patients with Hgb ≥11 g/dL at month 1 were older, more likely male, had higher albumin and lower TSAT, but did not have a lower burden of comorbidities. Hgb at month 1 was inversely associated with first-year mortality (adjusted HR for 1 g/dL higher Hgb = 0.89; 95% CI: 0.82-0.96) despite minimal differences in Hgb at month 4 (see Table, where Hgb is categorized). Patients with lower Hgb at month 1 received greater ESA doses over the first 3 months of HD and achieved the largest Hgb increases over these 3 months. In contrast, mean IV iron dose over the first 3 months varied much less by month 1 Hgb level. Additional adjustment for ESA and IV iron doses over the first 3 months of HD had minimal impact on the mortality HR = 0.90 (95% CI: 0.82-1.00). CONCLUSIONS: These results support our hypothesis that management of anemia before the start of HD may improve survival during the first year of HD treatment. High doses of ESA and IV iron did not appear to explain the association between low Hgb and mortality, though a more formal mediation analysis is required. A limitation of this analysis is the lack of available data on pre-HD treatment with ESA or iron; we also cannot rule out residual confounding due to better health status and/or pre-HD care in patients who start HD with higher Hgb.

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