Hemoglobin level and risk of hospitalization and mortality in children on peritoneal dialysis

Background: Clinical practice guidelines for management of anemia in children with end-stage kidney disease (ESKD) remain largely opinion-based. In this study, we evaluated the risk of mortality and hospitalization by hemoglobin (Hb) level in a large prevalent population of U.S. children on peritoneal dialysis (PD).

Methods: Hemoglobin levels in prevalent PD patients from the 2005 End Stage Renal Disease Clinical Performance Measures Project were linked with 5-year mortality and 4-year hospitalization records from the United States Renal Data System.

Results: Of the 468 patients included in the study, the mean age was 11 years, 55 % were male, 67 % were white, 254 (54 %) were hospitalized, and 23 (5 %) died. Median (interquartile range) Hb levels were 11.7 (10.7–12.6) g/dl, and 30 % had Hb levels of <11 g/dl. In adjusted survival analysis, Hb thresholds of 10, 11, or 12 g/dl were not associated with a significant difference in risk of death. The incidence rate ratio (IRR) of hospitalization for patients with a mean Hb of ≥11 g/dl was 0.56 (95 % CI 0.43–0.73). Compared to a reference range of Hb of 11 to <12, Hb of ≥12 g/dl was not associated with a significant difference in hospitalization risk (IRR 0.88; 95 % CI 0.61–1.25). Using age- and sex specific cut-offs for anemia, children who were not anemic had a 27 % decreased risk of hospitalization compared to those with anemia (IRR 0.73; 95 % CI 0.55–0.97). Compared to the first erythropoiesis stimulating agent (ESA) dosing quartile, higher ESA doses were associated with an increased risk of both hospitalization and mortality.

Conclusions: U.S. children on PD with Hb levels of ≥11 g/dl were less likely to be hospitalized but had no observed difference in mortality. Children who were not anemic were also less likely to be hospitalized. Further study is necessary to elucidate whether a single optimal Hb level or a range applies to the pediatric ESKD population.