Comparative effectiveness of two anemia management strategies for complex elderly dialysis patients

Med Care. 2014 Mar;52 Suppl 3(0 3):S132-9. doi: 10.1097/MLR.0b013e3182a53ca8.


Background: Randomized trials found that use of erythropoiesis-stimulating agents to target normal hematocrit (Hct) levels (>39%) compared with 27%-34.5% increases cardiovascular risk and mortality among chronic kidney disease patients. However, the effects of the most widely used Hct target in the past 2 decades, 34.5%-39%, have never been examined.

Objective: To compare the effects of 2 Hct target strategies-30.0%-34.5% (low) and 34.5%-39.0% (mid) in a high-risk population: elderly dialysis patients with significant comorbidities.

Research design: Observational data from the US Renal Data System were used to emulate a randomized trial in which patients were assigned to either Hct strategy. Follow-up started after completing 3 months of hemodialysis and ended 6 months later. We conducted the observational analogs of intention-to-treat and per-protocol analyses. Inverse-probability weighting was used to adjust for measured time-dependent confounding by indication.

Subjects: A total of 22,474 elderly patients with both diabetes and cardiovascular disease who initiated hemodialysis in 2006-2008.

Measures: Hazard ratios (HRs) and survival probabilities for all-cause mortality and a composite cardiovascular and mortality endpoint.

Results: The intention-to-treat HR (95% confidence interval) for mid versus low Hct strategy was 1.05 (0.99-1.11) for all-cause mortality and 1.03 (0.98-1.08) for the composite endpoint. The per-protocol HR (95% confidence interval) for mid versus low Hct strategy was 0.98 (0.78-1.24) for all-cause mortality and 1.00 (0.81-1.24) for the composite outcome.

Conclusions: Among hemodialysis patients, we did not find differences in 6-month survival or cardiovascular risk between clinical strategies that target Hct at 30.0%-34.5% versus 34.5%-39.0%.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Anemia, Iron-Deficiency / drug therapy*
  • Anemia, Iron-Deficiency / epidemiology*
  • Cardiovascular Diseases / epidemiology*
  • Cardiovascular Diseases / therapy
  • Comorbidity
  • Dose-Response Relationship, Drug
  • Drug Dosage Calculations
  • Epoetin Alfa
  • Erythropoietin / administration & dosage*
  • Female
  • Hematinics / administration & dosage
  • Humans
  • Kidney Failure, Chronic / epidemiology*
  • Kidney Failure, Chronic / therapy
  • Male
  • Recombinant Proteins / administration & dosage
  • Renal Dialysis / statistics & numerical data*
  • Risk Factors
  • Survival Analysis
  • Treatment Outcome
  • United States


  • Hematinics
  • Recombinant Proteins
  • Erythropoietin
  • Epoetin Alfa