Effect of erythropoietin levels on mortality in old age: the Leiden 85-plus Study

Background

The production of erythropoietin is triggered by impaired oxygen delivery to the kidney, either because of anemia or hypoxemia. High erythropoietin levels have been shown to predict the risk of death among patients with chronic heart failure. We investigated the prognostic value of elevated erythropoietin levels on mortality among very elderly people in the general population.

Methods

The Leiden 85-plus Study is a population-based prospective follow-up study involving 599 people aged 85 years in Leiden, the Netherlands, enrolled between September 1997 and September 1999. Erythropoietin levels were determined at age 86. For this analysis, we included 428 participants with a creatinine clearance of at least 30 mL/min. Mortality data, recorded until Feb. 1, 2008, were obtained from the municipal registry.

Results

During follow-up, 324 (75.7%) participants died. Compared with participants whose erythropoietin levels were in the lowest tertile (reference group), those whose levels were in the middle tertile had a 25% increased risk of death (hazard ratio HR] 1.25, 95% confidence interval CI] 0.95–1.64), and those whose levels were in the highest tertile had a 73% increased risk (HR 1.73, 95% CI 1.32–2.26) (p value for trend < 0.01). The association between erythropoietin levels and mortality remained largely unchanged after we adjusted for sex, creatinine clearance, hemoglobin level, comorbidity, smoking status and C-reactive protein level, and was similar for deaths from cardiovascular and noncardiovascular causes.

Interpretation

Among people aged 85 years and older, elevated erythropoietin levels were associated with an increased risk of death, independent of hemoglobin levels.Decreased oxygen availability in the kidney triggers the peritubular capillary lining cells within the kidney to produce erythropoietin — the principal regulator of red blood cell mass.¹ Impaired oxygen delivery to the kidney can result from various pathophysiologic mechanisms, such as anemia, hypoperfusion due to renal arteriosclerosis, decreased renal blood flow or heart failure, and decreased oxygen saturation due to diseases such as chronic obstructive pulmonary disease.^1–5Studies involving patients with chronic heart failure have shown that high erythropoietin levels predict poor survival.^6–11 However, whether this prognostic value is limited to patients with heart failure or whether it is generalizable to very elderly people regardless of specific pathologic conditions has not been studied. We conducted this study to investigate whether high levels of erythropoietin predict mortality among very elderly people in the general population.