23 In the weighted regression models, survival was similar among the three hypothetical ESA doses (15 000 U/week, 30 000 U/week and 45 000 U/week). In contrast, in the standard unweighted regression model, erythropoietin doses of 10 000–20 000 U/week and <10 000 U/week were associated with 18% and 27% reductions in mortality, respectively, compared with the reference dose of 20 000–30 000 U/week. On the other hand, doses of 30 000–40 000 U/week
and >40 000 U/week were associated with 16% and 26% increases in mortality, respectively. Another selleck products analysis of 27 791 prevalent haemodialysis patients found that HR estimates were no longer significant when using a marginal structural model that included increasing covariate history and reduced weight truncation.24 The authors concluded that erythropoietin dose was not associated with increased mortality in a marginal structural model analysis that ‘completely’ addressed confounding by PS-341 solubility dmso indication. Similarly, Bradbury et al. reported increased mortality with high erythropoietin dose (adjusted HR 1.21, 95% CI 1.15–1.28 per log unit increase) using a Fresenius Medical Care database of 22 955 prevalent haemodialysis patients.25 Temporal association between erythropoietin dose and mortality was assessed by additional analyses by lagging
erythropoietin dose at 1 and 2 months intervals, with haemoglobin values lagged at 2 and 3 months. These lagged, time-dependent analyses did not demonstrate any association between erythropoietin Ribonucleotide reductase dose and mortality. In contrast, Brookhart et al. characterized each US dialysis centre’s annual anaemia management practice by estimating its typical use of ESAs and iron in 269 717 incident patients in the first 6 months of initiating haemodialysis using US Medicare data.26 Correlation between centre-level patterns of ESA use on 1 year mortality was studied. Mortality rates were highest in patients with
haematocrit levels <30% (2.1%). As the haematocrit increased, mortality rates decreased. Mortality rates for haematocrit levels of 30–32.9%, 33–35.9% and ≥36% were 1.3%, 0.9% and 0.7%, respectively. In patients with haematocrit levels <30%, higher quintiles of ESA dosage were associated with lower mortality. On the other hand, larger doses of ESAs were associated with higher mortality in patients with haematocrit levels of ≥33%. This analysis was performed using centre-level data rather than patient-level data. Hence, these results should be interpreted with caution. Similarly, Regidor et al. analysed a cohort of 58 058 prevalent haemodialysis patients from the DaVita dialysis organization.27 In the time-dependent multivariate adjusted Cox proportional hazard model, all haemoglobin levels below 115 g/L were associated with inferior survival compared with a haemoglobin level of 115–120 g/L. In contrast, inferior survival was observed only when haemoglobin levels were above 135 g/L. Results were similar for cardiovascular deaths.