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The Third National Health and Nutrition Examination Survey (1988-1994)

Brad C. Astor, PhD, MPH; Paul Muntner, PhD, MHS; Adeera Levin, MD, FRCPC; Joseph A. Eustace, MB, MRCPI, MHS; Josef Coresh, MD, PhD

Arch Intern Med. 2002;162:1401-1408.

Background  Kidney failure is known to cause anemia, which is associated with a higher risk of cardiac failure and mortality. The impact of milder decreases in kidney function on hemoglobin levels and anemia in the US population, however, is unknown.

Methods  We analyzed a population-based sample of 15419 participants 20 years and older in the Third National Health and Nutrition Examination Survey, conducted from 1988 to 1994.

Results  Lower kidney function was associated with a lower hemoglobin level and a higher prevalence and severity of anemia below, but not above, an estimated glomerular filtration rate (GFR) of 60 mL/min per 1.73 m². Adjusted to the age of 60 years, the predicted median hemoglobin level among men (women) decreased from 14.9 (13.5) g/dL at an estimated GFR of 60 mL/min per 1.73 m² to 13.8 (12.2) g/dL at an estimated GFR of 30 mL/min per 1.73 m² and to 12.0 (10.3) g/dL at an estimated GFR of 15 mL/min per 1.73 m². The prevalence of anemia (hemoglobin level <12 g/dL in men and <11 g/dL in women) increased from 1% (95% confidence interval, 0.7%-2%) at an estimated GFR of 60 mL/min per 1.73 m² to 9% (95% confidence interval, 4%-19%) at an estimated GFR of 30 mL/min per 1.73 m² and to 33% (95% confidence interval, 11%-67%) at an estimated GFR of 15 mL/min per 1.73 m² among men and to 67% (95% confidence interval, 30%-90%) at an estimated GFR of 15 mL/min per 1.73 m² among women. An estimated GFR of 15 to 60 mL/min per 1.73 m² was present in 4% of the entire population and in 17% of the individuals with anemia.

Conclusion  Below an estimated GFR of 60 mL/min per 1.73 m², lower kidney function is strongly associated with a higher prevalence of anemia among the US adult population.

From the Departments of Epidemiology (Drs Astor and Coresh) and Biostatistics (Dr Coresh), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; the Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins University, Baltimore (Drs Astor and Coresh); the Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, La (Dr Muntner); the Division of Nephrology, Department of Medicine, St Paul's Hospital, University of British Columbia, Vancouver (Dr Levin); and the Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore (Drs Eustace and Coresh). Dr Levin is an advisor/consultant to Amgen, Inc, Ortho Biotech Inc, Janssen-Cilag, and F. Hoffmann-La Roche in North America and internationally. She is involved in studies with Ortho Biotech Inc and Amgen, Inc, and has received honoraria for presentations. These companies have no affiliation with this article, and they have not influenced the article in any way.

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