The Study Of The Association Between Hemoglobin Variability And Morbidity/Mortality Of Cardiovascular And Cerebrovascular Events In Maintenance Hemodialysis Patients

Part One:The Study of the Association Betwween Hemoglobin Variability and the Clinical Adverse Events in Maintenance Hemodialysis Patients1. ObjectiveThe appropriate management of anaemia is an important aspect of maintenance hemodialysis patient’s care. The concern about what constitutes appropriate anaemia management has increased due to the results from clinical trials. The purpose of this study was to describe and compare the differences of hemoglobin level and its variability between groups of maintenance hemodialysis patients whether developed cardiovascular events, cerebrovascular events or death.2. MethodsData were analyzed from74hemodialysis end-stage renal disease patients. During a12-month period, hemoglobin and serum biochemical levels were measured every3months at our dialysis center from February2011to February2012. General characteristics, the level and variability of hemoglobin were described and compared between groups divided according to the occurrence of clinical adverse events including cardiovascular events, cerebrovascular events or death. The variability was analyzed by standard deviation, coefficient variation, mean differences, residual standard deviation, and standard deviation across thresholds.3. Results74cases of maintenance hemodialysis end-stage renal disease patients were included in the analysis (Mean age was59.7±12.8years,47.3%were male, dialysis age was4.57±2.94years and BMI was23.03±3.46kg/m2). During the analyzed period,15cases (20.27%) developed cardiovascular events,17cases (22.97%) developed cerebrovascular events and11cases (14.86%) dead. The mean hemoglobin concentration of the dialysis center was93.16±21.85g/l, and individual mean hemoglobin concentration was93.16±18.09g/l, mean standard deviation was12.27±6.21g/l, mean coefficient variation was0.13±0.07, mean differences between4 times results was15.46±9.07g/l, residual standard deviation was12.34±7.64g/l, and the standard deviation across thresholds was23.26±13.12g/l.Of six patterns of hemoglobin level fluctuation, consistently low (<110g/1) was the most comment pattern (44cases,59.50%). The proportion of Hemoglobin variability varies from38%to77%, depending upon the definition used.The hemoglobin concentration in the group occured clinical adverse events was significantly lower (t=2.466, P=0.016) than non-events group, while residual standard deviation was higher (t=-2.225, P=0.029). And mean coefficient variation was higher (t=-2.083, P=0.041) in the cerebrovascular disease group than non-cerebrovascular disease group.4. ConclusionsHemoglobin variability is a common occurrence in maintenance hemodialysis patients with anemia. Lower hemoglobin level and higher standard deviation across thresholds are associated with a higher risk of clinical adverse events, while higher residual standard deviation may be associated with a higher risk of cerebrovascular disease.Part Two:The Impact of Increasing Hemoglobin Testing Frequency on Maintaining the Stability of Hemoglobin Level in Maintenance Hemodialysis Patients1. ObjectiveTo explore the impact of increasing hemoglobin concentration testing frequency on maintaining the stability of the dialysis center’s and individual hemoglobin level in maintenance hemodialysis patients, and provide effective evidences for optimizing clinical therapy strategy.2. Methods58cases maintenance hemodialysis end-stage renal disease patients treated from June2011to February2013at our dialysis center were included in the analysis. Hemoglobin concentration tested every3months during June2011to February2012was set as Q3M group, and tested every month during June2012to February2013set as QM group. This part of study analyzed datas from same months of two groups to describe and compare the differences of the dialysis center’s and individual hemoglobin level and its variability with different testing frequency.3. ResultsAmong58patients, the ratio of male to female was27:31, mean age was60.67±13years, dialysis age was4.43±2.9years,52cases have hypertension (89.7%) and17cases (29.3%) have diabetes. Compared with tested per3months, QM group’s mean hemoglobin concentration increased from96.63g/l to101.64g/l, mean standard deviation decreased from22.55g/l to18.12g/l (t=3.195, P=0.002), and the individual mean hemoglobin concentration increased from96.63＋17.07g/l to101.64±16.31g/l (t=2.617, P=0.109), coefficient variation significantly decreased from0.14±0.06to0.09±0.05(t=18.69, P<0.001), differences between3results significantly decreased from16.4±8.81g/l to7.84±4.41g/l (t=43.76, P<0.001), residual standard deviation significantly decreased from12.69±7.89g/l to7.61±4.06g/l (t=19.01, P<0.001). The proportion of Hemoglobin variability decreased; however, difference has not statistically significant.4. ConclusionsIn conclusion, proper increasing the testing frequency of hemoglobin concentration in maintenance hemodialysis patients can significantly enhance the dialysis center’s and individual hemoglobin level and its stability.Part Three:The Study of the Association Between Hemoglobin Variability and Morbidity/Mortality of Cardiovascular and Cerebrovascular Events in Maintenance Hemodialysis Patients1. ObjectiveThe purpose of this study is to compare the differences of morbidity/mortality of cardiovascular and cerebrovascular events between groups of different hemoglobin level and variability in maintenance hemodialysis patients, and explore the association.2. Methods80cases of maintenance hemodialysis end-stage renal disease patients recruited into this9-month period prospective study, from June2012to February2013. Hemoglobin concentration was measured monthly, while the rest serum biochemical tests were preformed every3months. Patients were grouped by the level of hemoglobin concentration and different indicators of hemoglobin variability. The observational end point was death, cardiovascular or cerebrovascular events.The influence of variables, such as general clinical manifestations, serum biochemical results, hemoglobin concentration and variability indicators on the occurrence of death, cardiovascular and cerebrovascular events was analyzed by using t-test, univariate and multivariate Logistic regression analysis and survival analysis. Hazard ratio was calculated adjusted for baseline characteristics of groups using Cox regression.3. Results80cases of maintenance hemodialysis end-stage renal disease patients were included in the study. The ratio of male to female was1.22:1, mean age was60.8±12.79years, dialysis age was4.27±3.09years and BMI was22.72±3.3kg/m2,74cases had hypertension (92.5%) and24cases (30%) have diabetes.During the period of follow-up,6cases (7.5%) developed cardiovascular events,4cases (5%) developed cerebrovascular events and10cases (12.5%) died. The mean hemoglobin concentration of the dialysis center was101.62±17.67g/l, and individual mean hemoglobin concentration was101.62±15.24g/l, mean standard deviation was8.91±4.4g/l, mean coefficient variation was0.09±0.05, mean differences between9times results was7.83±4.1g/l, residual standard deviation was7.58±3.97g/l, and the standard deviation across thresholds was19.97±14.67g/l. Of six patterns of hemoglobin level fluctuation, consistently low (<110g/l) was the most comment pattern (34cases,43%). The proportion of hemoglobin variability varies from53.8%to87%, depending upon the definition used.Analysis of multiple stepwise regressions showed that, the independent risk factors of the clinical adverse events were the hemoglobin standard deviation (OR=1.162, P=0.030), coefficient variation (%)(OR=1.17, P=0.009), mean differences between9times results (OR=1.292, P=0.006), while the hemoglobin concentration was protective factor (OR=0.95, P=0.02); the independent risk factors of the cerebrovascular events were the hemoglobin standard deviation (OR=1.155, P=0.034) and coefficient variation (%)(OR=1.231, P=0.020); the independent risk factors of the cardiovascular events was mean differences between9times results (OR=1.358, P=0.019). Multiple stepwise regression analysis showed that mean differences between9times results was an independent risk factor (HR=3.13, P=0.006) of death, while the hemoglobin concentration was protective factor (HR=0.849, P=0.012).4. ConclusionsThe results of this prospective study show that, hemoglobin variability is a common occurrence in maintenance hemodialysis patients, and the consistently low patterns (<110g/l) is the most comment hemoglobin level fluctuation pattern. Hemoglobin concentration is a protective factor for total clinical adverse events and death, Hemoglobin standard deviation and coefficient variation are risk factors for cerebrovascular events, and mean differences between9times results is a risk factor for cardiovascular events.