Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality
It has been previously reported that a higher erythropoiesis stimulating agent (ESA) dose in hemodialysis patients is associated with adverse outcomes including mortality; however the causal relationship between ESA and mortality is still hotly debated. We hypothesize ESA dose indeed exhibits a dire...
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| Format: | Article |
| Language: | English |
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Wiley
2016-01-01
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| Series: | International Journal of Nephrology |
| Online Access: | http://dx.doi.org/10.1155/2016/6087134 |
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| author | Elani Streja Jongha Park Ting-Yan Chan Janet Lee Melissa Soohoo Connie M. Rhee Onyebuchi A. Arah Kamyar Kalantar-Zadeh |
| author_facet | Elani Streja Jongha Park Ting-Yan Chan Janet Lee Melissa Soohoo Connie M. Rhee Onyebuchi A. Arah Kamyar Kalantar-Zadeh |
| author_sort | Elani Streja |
| collection | DOAJ |
| description | It has been previously reported that a higher erythropoiesis stimulating agent (ESA) dose in hemodialysis patients is associated with adverse outcomes including mortality; however the causal relationship between ESA and mortality is still hotly debated. We hypothesize ESA dose indeed exhibits a direct linear relationship with mortality in models of association implementing the use of a marginal structural model (MSM), which controls for time-varying confounding and examines causality in the ESA dose-mortality relationship. We conducted a retrospective cohort study of 128 598 adult hemodialysis patients over a 5-year follow-up period to evaluate the association between weekly ESA (epoetin-α) dose and mortality risk. A MSM was used to account for baseline and time-varying covariates especially laboratory measures including hemoglobin level and markers of malnutrition-inflammation status. There was a dose-dependent positive association between weekly epoetin-α doses ≥18 000 U/week and mortality risk. Compared to ESA dose of <6 000 U/week, adjusted odds ratios (95% confidence interval) were 1.02 (0.94–1.10), 1.08 (1.00–1.18), 1.17 (1.06–1.28), 1.27 (1.15–1.41), and 1.52 (1.37–1.69) for ESA dose of 6 000 to <12 000, 12 000 to <18 000, 18 000 to <24 000, 24 000 to <30 000, and ≥30 000 U/week, respectively. High ESA dose may be causally associated with excessive mortality, which is supportive of guidelines which advocate for conservative management of ESA dosing regimen in hemodialysis patients. |
| format | Article |
| id | doaj-art-cfbe9e1fe3ec4b5c90e2ce838ac89e55 |
| institution | Kabale University |
| issn | 2090-214X 2090-2158 |
| language | English |
| publishDate | 2016-01-01 |
| publisher | Wiley |
| record_format | Article |
| series | International Journal of Nephrology |
| spelling | doaj-art-cfbe9e1fe3ec4b5c90e2ce838ac89e552025-02-03T01:20:27ZengWileyInternational Journal of Nephrology2090-214X2090-21582016-01-01201610.1155/2016/60871346087134Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine CausalityElani Streja0Jongha Park1Ting-Yan Chan2Janet Lee3Melissa Soohoo4Connie M. Rhee5Onyebuchi A. Arah6Kamyar Kalantar-Zadeh7Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USADepartment of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USAHarold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USAIt has been previously reported that a higher erythropoiesis stimulating agent (ESA) dose in hemodialysis patients is associated with adverse outcomes including mortality; however the causal relationship between ESA and mortality is still hotly debated. We hypothesize ESA dose indeed exhibits a direct linear relationship with mortality in models of association implementing the use of a marginal structural model (MSM), which controls for time-varying confounding and examines causality in the ESA dose-mortality relationship. We conducted a retrospective cohort study of 128 598 adult hemodialysis patients over a 5-year follow-up period to evaluate the association between weekly ESA (epoetin-α) dose and mortality risk. A MSM was used to account for baseline and time-varying covariates especially laboratory measures including hemoglobin level and markers of malnutrition-inflammation status. There was a dose-dependent positive association between weekly epoetin-α doses ≥18 000 U/week and mortality risk. Compared to ESA dose of <6 000 U/week, adjusted odds ratios (95% confidence interval) were 1.02 (0.94–1.10), 1.08 (1.00–1.18), 1.17 (1.06–1.28), 1.27 (1.15–1.41), and 1.52 (1.37–1.69) for ESA dose of 6 000 to <12 000, 12 000 to <18 000, 18 000 to <24 000, 24 000 to <30 000, and ≥30 000 U/week, respectively. High ESA dose may be causally associated with excessive mortality, which is supportive of guidelines which advocate for conservative management of ESA dosing regimen in hemodialysis patients.http://dx.doi.org/10.1155/2016/6087134 |
| spellingShingle | Elani Streja Jongha Park Ting-Yan Chan Janet Lee Melissa Soohoo Connie M. Rhee Onyebuchi A. Arah Kamyar Kalantar-Zadeh Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality International Journal of Nephrology |
| title | Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality |
| title_full | Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality |
| title_fullStr | Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality |
| title_full_unstemmed | Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality |
| title_short | Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality |
| title_sort | erythropoietin dose and mortality in hemodialysis patients marginal structural model to examine causality |
| url | http://dx.doi.org/10.1155/2016/6087134 |
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