title: The Korean Clinical Research Center for End-Stage Renal Disease Study Validates the Association of Hemoglobin and Erythropoiesis-Stimulating Agent Dose with Mortality in Hemodialysis Patients.
abstract: BACKGROUND
  Anemia is an important risk factor for mortality in hemodialysis (HD) patients. However, higher hemoglobin (Hb) is not necessarily better, as seen in several studies. This study aimed to validate the clinical use of an Hb target of 10-11 g/dL in Korean HD patients.
  
  
  METHODS
  A total of 1,276 HD patients from the Clinical Research Center (CRC) for End-Stage Renal Disease (ESRD) were investigated in a prospective observational study. Cox proportional hazard analysis was conducted for each category of time-dependent Hb level and erythropoiesis-stimulating agent (ESA) dose, with subgroup analysis stratified by age and diabetes status.
  
  
  RESULTS
  Using a reference Hb level of 10-11 g/dL, the hazard ratios (HRs) of death were 5.12 (95% confidence interval [CI], 2.62-10.02, P <0.05) for Hb level <9.0 g/dL, and 2.03 (CI, 1.16-3.69, P <0.05) for Hb level 9.0-10.0 g/dL, after adjustment for multiple clinical variables. However, an Hb level ≥11 g/dL was not associated with decreased mortality risk. In an adjusted model categorized by Hb and ESA dose, the risk of death at an Hb level <10 g/dL and a higher dose of ESA (≥126 U/kg/week) had an HR of 2.25 (CI, 1.03-4.92, P <0.05), as compared to Hb level 10-11 g/dL and a lower dose of ESA. In subgroup analysis, those older than 65 years or who were diabetic had greater risk for mortality only in Hb category <9.0 g/dL. However, there was no significant interaction between age or diabetes status and Hb.
  
  
  CONCLUSIONS
  Using CRC-ESRD data, we validated the association between Hb and ESA dose and mortality in Korean HD patients. The clinical practice target of an Hb of 10-11 g/dL before the new KDIGO guideline era seems reasonable considering its survival benefit in HD patients.
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Owen
authors.initials: O
authors.lastname: Kwon
authors.affiliation: Department of Statistics, Kyungpook National University, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Hye Min
authors.initials: HM
authors.lastname: Jang
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Hee-Yeon
authors.initials: HY
authors.lastname: Jung
authors.affiliation: Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Yon Su
authors.initials: YS
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Shin-Wook
authors.initials: SW
authors.lastname: Kang
authors.affiliation: Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Chul Woo
authors.initials: CW
authors.lastname: Yang
authors.affiliation: Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Nam-Ho
authors.initials: NH
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Ji-Young
authors.initials: JY
authors.lastname: Choi
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Jang-Hee
authors.initials: JH
authors.lastname: Cho
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Chan-Duck
authors.initials: CD
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Yong-Lim
authors.initials: YL
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea; Clinical Research Center for End-Stage Renal Disease in Korea, Daegu, Korea.
authors.forename: Sun-Hee
authors.initials: SH
authors.lastname: Park
mesh_terms: D015331:Cohort Studies; D004305:Dose-Response Relationship, Drug; D005260:Female; D006397:Hematinics / Q000494:pharmacology*; D006454:Hemoglobins / Q000378:metabolism*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D015203:Reproducibility of Results; D056910:Republic of Korea
chemical_list: D006397:Hematinics; D006454:Hemoglobins