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目的:探讨腹膜透析（peritoneal dialysis，PD）患者血红蛋白变异性（hemoglobin variability，Hb-var）与全因死亡及心血管疾病死亡风险的关系，以期为降低PD人群死亡风险提供依据。方法:该研究为多中心、回顾性队列研究，收集2008年7月1日至2019年12月31日在南方医科大学南方医院、南方医科大学顺德医院、佛山市第一人民医院及赣州市人民医院规律PD患者的临床资料。以PD前基线及PD后第1年内血红蛋白计算Hb-var，根据第1年Hb-var三分位数将患者分为低变异性组、中变异性组和高变异性组，比较3组基线临床资料的差异。随访终点为患者死亡、转血液透析、转肾移植、转其他中心、失访或截至2021年12月31日。采用Cox回归分析模型分析第1年Hb-var与全因死亡及心血管疾病死亡的相关性，并使用Fine-Gray竞争风险回归模型评估竞争事件对死亡风险的影响。结果:该研究纳入1 562例PD患者，年龄（47.6±13.8）岁，男性821例（52.6%），基线血红蛋白为81（69，94）g/L，PD第1年Hb-var为26.6（16.7，40.3）g/L。低变异性组（<20.0 g/L）、中变异性组（20.0～35.5 g/L）、高变异性组（≥35.5 g/L）患者年龄、体重指数、血清白蛋白、血红蛋白、血清肌酐、血清钙、血清磷、全段甲状旁腺素及肾素-血管紧张素系统抑制剂使用比例的差异均有统计学意义（均 P<0.05）。随访时间为33（19，51）个月，患者死亡208例（13.3%），其中心血管疾病死亡111例（53.4%）。多因素Cox回归分析结果显示，第1年高Hb-var是PD患者全因死亡（ HR=0.98，95% CI 0.97～0.99， P=0.018）和心血管疾病死亡（ HR=0.98，95% CI 0.97～0.99， P=0.041）风险低的独立影响因素。以低变异性组为参照，高变异性组全因死亡（ HR=0.56，95% CI 0.37～0.82， P=0.003）及心血管疾病死亡（ HR=0.54，95% CI 0.31～0.95， P=0.032）风险最低。竞争风险回归模型分析结果显示，第1年Hb-var与全因死亡（ HR=0.98，95% CI 0.97～0.99， P=0.041）和心血管疾病死亡（ HR=0.98，95% CI 0.97～0.99， P=0.039）风险仍呈负相关。 结论:对于基线贫血严重PD患者，第1年高Hb-var与低全因死亡及心血管疾病死亡风险相关。

Objective:To explore the relationship between hemoglobin variability (Hb-var) and risk of all-cause death and cardiovascular death in patients with peritoneal dialysis (PD), and to provide basis for reducing the risk of death in PD patients.Methods:It was a multicenter retrospective cohort study. The clinical data of regular PD patients from Nanfang Hospital of Southern Medical University, Shunde Hospital of Southern Medical University, Foshan First People's Hospital and Ganzhou People's Hospital from July 1, 2008 to December 31, 2019 were collected. Hb-var was calculated based on hemoglobin at baseline before PD and in the first year after PD. The patients were divided into low Hb-var group, moderate Hb-var group and high Hb-var group according to the tertiles of first year Hb-var, and the differences of baseline clinical data among three groups were compared. Follow-up endpoints included death, transfer to hemodialysis, transfer to kidney transplantation, transfer to other centers, loss of follow-up, or on December 31, 2021. Cox regression analysis model was used to analyze the association of the first-year Hb-var with all-cause death and cardiovascular death. Fine-Gray competitive risk regression model was used to evaluate the impact of competitive events on mortality risk.Results:A total of 1 562 patients with PD were included in the study, aged (47.6±13.8) years old, with 821 males (52.6%) and baseline hemoglobin of 81 (69, 94) g/L. Hb-var in the first year of PD was 26.6 (16.7, 40.3) g/L. There were statistically significant differences in age, body mass index, serum albumin, hemoglobin, serum creatinine, serum calcium, serum phosphorus, intact parathyroid hormone and the proportion of renin-angiotensin system inhibitors among low Hb-var group (<20.0 g/L), moderate Hb-var group (20.0-35.5 g/L) and high Hb-var group (≥35.5 g/L, all P<0.05). The follow-up time was 33 (19, 51) months, and 208 patients (13.3%) died, among which 111 patients (53.4%) died of cardiovascular death. Multivariate Cox regression analysis showed that the higher Hb-var in the first year, the lower the risk of all-cause death ( HR=0.98, 95% CI 0.97-0.99, P=0.018) and cardiovascular death ( HR=0.98, 95% CI 0.97-0.99, P=0.041) in PD patients. Compared with low Hb-var group, the risk of all-cause death ( HR=0.56, 95% CI 0.37-0.82, P=0.003) and cardiovascular death ( HR=0.54, 95% CI 0.31-0.95, P=0.032) was lowest in the high Hb-var group. The competitive risk regression model analysis showed that Hb-var in the first year was still negatively correlated with the risk of all-cause death ( HR=0.98, 95% CI 0.97-0.99, P=0.041) and cardiovascular death ( HR=0.98, 95% CI 0.97-0.99, P=0.039). Conclusion:High Hb-var in the first year is associated with low risk of all-cause death and cardiovascular death in PD patients with severe anemia at baseline.