The prevalence and severity of anemia differ between diabetic and non-diabetic patients. We investigated whether the effect of hemoglobin (Hb) on patient outcome was affected by the presence or absence of diabetes among Japanese patients receiving chronic hemodialysis (HD).
We enrolled 149,308 patients from a nationwide dialysis registry in Japan at the end of 2012 (mean age, 67.6 ± 12.3 years; male, 61.7%; diabetes, 43.5%; median dialysis duration, 65 months) who underwent three HD sessions weekly. One-year all-cause and cardiovascular (CV) mortality were assessed using Cox regression analysis and competing-risks regression analysis. We used multiple imputation to deal with missing covariate data.
Baseline Hb and serum ferritin levels were independently associated with all-cause and CV mortality. In non-diabetic patients, a significantly higher risk for all-cause mortality compared to the reference group (10 to 11 g/dL) was observed in patients with Hb < 8 g/dL (hazard ratio (HR): 1.266; 95% confidence interval (CI) 1.097–1.460) and 8 to 9 g/dL(HR: 1.153; 95% CI 1.030–1.290). On the other hand, diabetic HD patients in the same Hb category group did not have increased risk of all-cause mortality.
We found that non-diabetic HD patients had an increased risk of all-cause mortality if they had lower Hb levels, whereas the effect of Hb levels on mortality was attenuated in diabetic HD patients. These data suggest that the association between Hb levels and mortality rate could be different between diabetic and non-diabetic HD patients.
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The authors thank the participants in the dialysis registry of the JSDT, the Committee of the Renal Data Registry, and all personnel at the institutions that participated in this survey. The data used in this study were provided by JSDT. The interpretation and reporting of these data are the responsibility of the authors, which is in no way seen as an official policy or interpretation of the JSDT. All authors have approved the manuscript.
There was no financial support for the present study.
Conflict of interest
Y.M. received honoraria from Kyowa Kirin Co., Ltd. and Chugai Pharmaceutical Co., Ltd. M.A. chairs courses endowed by Chugai Pharmaceutical Co., Ltd., Nikkiso Co., Ltd., NIPRO Corporation, Ono Pharmaceutical Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Terumo Corporation, and Toray Medical Co., Ltd. I.M. received honoraria from Kyowa Kirin Co., Ltd., Chugai Pharmaceutical Co., Ltd., and Kissei Pharmaceutical Co., Ltd. T.Y. received honoraria from Kyowa Kirin Co., Ltd. and Chugai Pharmaceutical Co., Ltd. No other authors have any conflicts of interest to declare.
The Medical Ethics Committee of the JSDT approved the study protocol, and the study was conducted in accordance with the Declaration of Helsinki (2013).
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Supplementary file1 (DOCX 82 kb) Supplementary Table 1. Comparisons of the cause of death. Supplementary Table 2. Comparisons of the cause of CV death. Supplementary Table 3. HR and 95% CI of all-cause mortality before multiple imputation for missing variables. Supplementary Table 4. HR and 95% CI of all-cause mortality, analysis using Hb, TSAT and serum ferritin as continuous variable. Supplementary Table 5. SHR and 95% CI of CV mortality before multiple imputation for missing variables. Supplementary Table 6. SHR and 95% CI of CV mortality, analysis using Hb, TSAT and serum ferritin as continuous variable. Supplementary Table 7. Subgroup analyses of HR and 95% CI of all-cause mortality. Supplementary Table 8. Subgroup analyses of SHR and 95% CI of CV mortality. Supplementary Table 9. Subgroup analyses of HR and 95% CI of all-cause mortality, analysis using Hb, TSAT and serum ferritin as continuous variable. Supplementary Table 10. Subgroup analyses of SHR and 95% CI of CV mortality, analysis using Hb, TSAT and serum ferritin as continuous variable
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Maruyama, Y., Kanda, E., Kikuchi, K. et al. Association between anemia and mortality in hemodialysis patients is modified by the presence of diabetes. J Nephrol (2021). https://doi.org/10.1007/s40620-020-00879-x
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