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Streja E, Park J, Chan TY, et al. Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality. Int J Nephrol. 2016;2016:6087134doi: 10.1155/2016/6087134.
Streja, E., Park, J., Chan, T. Y., Lee, J., Soohoo, M., Rhee, C. M., Arah, O. A., & Kalantar-Zadeh, K. (2016). Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality. International journal of nephrology, 20166087134. https://doi.org/10.1155/2016/6087134
Streja, Elani, et al. "Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality." International journal of nephrology vol. 2016 (2016): 6087134. doi: https://doi.org/10.1155/2016/6087134
Streja E, Park J, Chan TY, Lee J, Soohoo M, Rhee CM, Arah OA, Kalantar-Zadeh K. Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality. Int J Nephrol. 2016;2016:6087134. doi: 10.1155/2016/6087134. Epub 2016 May 19. PMID: 27298736; PMCID: PMC4889858.
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Int J Nephrol. 2016;2016:6087134. doi: 10.1155/2016/6087134. Epub 2016 May 19.

Erythropoietin Dose and Mortality in Hemodialysis Patients: Marginal Structural Model to Examine Causality.

International journal of nephrology

Elani Streja, Jongha Park, Ting-Yan Chan, Janet Lee, Melissa Soohoo, Connie M Rhee, Onyebuchi A Arah, Kamyar Kalantar-Zadeh

Affiliations

  1. Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USA.
  2. Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USA; Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
  3. Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
  4. Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California, Irvine, Orange, CA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA; Division of Nephrology and Hypertension, School of Medicine, University of California, Irvine, Orange, CA, USA.

PMID: 27298736 PMCID: PMC4889858 DOI: 10.1155/2016/6087134

Abstract

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.

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