Baseline Hemoglobin and Outcomes in Advanced Chronic Kidney Disease with Moderate-to-Severe Myocardial Ischemia: A Secondary Analysis of the ISCHEMIA-CKD Trial
- 1Department of Cardiology, Acıbadem Bayındır Söğütözü Hospital, Ankara 06250, Türkiye
- 2Department of Cardiology, School of Medicine, Ankara Medipol University, Ankara 06050, Türkiye
Abstract
Background/Objectives: Hemoglobin may identify differences in prognosis among patients with advanced chronic kidney disease (CKD) and documented myocardial ischemia. We examined the shape of its association with clinical outcomes in ISCHEMIA-CKD. Methods: This exploratory observational secondary analysis included 758 randomized participants with baseline hemoglobin. The primary endpoint was the parent-trial composite of all-cause death or myocardial infarction (MI). Adjusted Cox regression with restricted cubic splines characterized the hemoglobin association. Mortality and pooled nonfatal MI were examined using Cox and competing-risk models. Results: Median hemoglobin was 11.1 g/dL; 247 participants experienced the primary endpoint. The adjusted association departed from log-linearity (p = 0.015), with higher hazard at lower hemoglobin and an uncertain upper limb. Relative to 11.1 g/dL, the hazard ratio (HR) at 8 g/dL was 1.98 (95% confidence interval [CI] 1.26–3.10). As a linear summary, the HR per 1 g/dL lower hemoglobin was 1.13 (95% CI 1.04–1.23) for the primary endpoint. Corresponding mortality associations were present, whereas pooled nonfatal MI showed no clear association (subdistribution HR 1.03, 95% CI 0.89–1.21). Exploratory treatment interaction tests provided no convincing evidence of effect modification (linear p = 0.059; spline p = 0.124). Conclusions: Among selected, clinically stable participants with advanced CKD and moderate-to-severe ischemia, lower baseline hemoglobin was associated with adverse prognosis. Nonlinearity and uncertainty at higher values argue against a single summary estimate or an inferred optimal target. These potentially confounded findings neither establish benefit from hemoglobin correction nor support hemoglobin-based selection of invasive versus conservative management.
Related
- Acute kidney injury due to hemoglobin cast nephropathy secondary to autoimmune hemolytic anemia: a case report.
- Stratified by baseline corticosteroid use: which advanced therapy works best for whom in ulcerative colitis?
- Prognostic value of baseline modified barium swallow for perioperative dysphagia in oropharyngeal cancer: Secondary analysis of ECOG-ACRIN E3311
- ST-Segment Elevation Myocardial Infarction Secondary to Aortic Root Thrombosis in a Patient With a Left Ventricular Assist Device
- Inferolateral ST-Segment Elevation Myocardial Infarction Secondary to Suspected Coronary Embolism in a Patient with Paroxysmal Atrial Fibrillation: A Case Report.
BibTeX
@article{mammadli2026baseline,
title = {{Baseline Hemoglobin and Outcomes in Advanced Chronic Kidney Disease with Moderate-to-Severe Myocardial Ischemia: A Secondary Analysis of the ISCHEMIA-CKD Trial}},
author = {Anar Mammadli and Erdem Diker},
journal = {Journal of Clinical Medicine},
year = {2026},
month = nov,
doi = {10.3390/jcm15218610},
url = {https://www.mdpi.com/2077-0383/15/21/8610},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Baseline Hemoglobin and Outcomes in Advanced Chronic Kidney Disease with Moderate-to-Severe Myocardial Ischemia: A Secondary Analysis of the ISCHEMIA-CKD Trial
AU - Anar Mammadli
AU - Erdem Diker
PY - 2026
DA - 2026/11/05
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15218610
UR - https://www.mdpi.com/2077-0383/15/21/8610
AB - Background/Objectives: Hemoglobin may identify differences in prognosis among patients with advanced chronic kidney disease (CKD) and documented myocardial ischemia. We examined the shape of its association with clinical outcomes in ISCHEMIA-CKD. Methods: This exploratory observational secondary analysis included 758 randomized participants with baseline hemoglobin. The primary endpoint was the parent-trial composite of all-cause death or myocardial infarction (MI). Adjusted Cox regression with restricted cubic splines characterized the hemoglobin association. Mortality and pooled nonfatal MI were examined using Cox and competing-risk models. Results: Median hemoglobin was 11.1 g/dL; 247 participants experienced the primary endpoint. The adjusted association departed from log-linearity (p = 0.015), with higher hazard at lower hemoglobin and an uncertain upper limb. Relative to 11.1 g/dL, the hazard ratio (HR) at 8 g/dL was 1.98 (95% confidence interval [CI] 1.26–3.10). As a linear summary, the HR per 1 g/dL lower hemoglobin was 1.13 (95% CI 1.04–1.23) for the primary endpoint. Corresponding mortality associations were present, whereas pooled nonfatal MI showed no clear association (subdistribution HR 1.03, 95% CI 0.89–1.21). Exploratory treatment interaction tests provided no convincing evidence of effect modification (linear p = 0.059; spline p = 0.124). Conclusions: Among selected, clinically stable participants with advanced CKD and moderate-to-severe ischemia, lower baseline hemoglobin was associated with adverse prognosis. Nonlinearity and uncertainty at higher values argue against a single summary estimate or an inferred optimal target. These potentially confounded findings neither establish benefit from hemoglobin correction nor support hemoglobin-based selection of invasive versus conservative management.
SN - 2077-0383
ER -