Davies Simon J, Phillips Louise, Naish Patrick F, Russell Gavin I
Department of Nephrology, North Staffordshire Hospital Trust, Stoke-on-Trent, UK.
Nephrol Dial Transplant. 2002 Jun;17(6):1085-92. doi: 10.1093/ndt/17.6.1085.
Comorbidity is the single most important determinant of outcome in patients on renal replacement therapy. The aims of this study were to evaluate a semi-quantitative approach to comorbidity scoring in predicting survival of patients commencing peritoneal dialysis (PD), and to establish the interaction between this and other known predictors of patient outcome, in particular membrane function, residual renal function (RRF) and plasma albumin.
Comorbidity was recorded in a prospective, single centre cohort study of 303 patients commencing on PD. Using seven disease domains, chosen to reflect the dominance of cardiovascular morbidity in the end-stage renal failure population, comorbidity was graded as '0' when absent, '1' when one or two, and '2' when three or more conditions were present. The Wright comorbidity index, which includes age within the scoring method, was also evaluated. RRF, plasma albumin and peritoneal solute transport were measured every 6 months. Patients were censored at death.
Median survival according to grade of comorbidity was 105, 42 and 29 months, respectively (P<0.0001), with good separation of the actuarial survival curves. Using Cox regression, the addition of age and the grade of comorbidity to Kt/V(urea), solute transport and plasma albumin increased the predictive power of the model. All were independent predictors of outcome with the exception of albumin. The Wright comorbidity index also enhanced the Cox model, although was not as powerful as when age and comorbidity were considered independently. At baseline, RRF was not different according to comorbidity unless diabetes was considered separately. Diabetics started with higher RRF, but after 6 months on PD this was the same as non-diabetic patients. Otherwise, initial rate of decline of RRF was similar across the comorbid grades, although the impact of higher drop-out due to earlier loss in patients with more comorbidity may have disguised earlier loss in these patients. Peritoneal solute transport tended to be higher in patients with increased comorbidity at baseline, chi(2) 13.8, P=0.032, and this was sustained with time on treatment.
Comorbidity has a quantitative effect on survival that is independent of age, RRF and membrane function in PD patients. Comorbidity also appears to be associated with increased solute transport at the start of treatment, which is sustained. With the exception of diabetes, grade of comorbidity does not have a profound effect on loss of RRF.
合并症是接受肾脏替代治疗患者预后的最重要单一决定因素。本研究的目的是评估一种合并症半定量评分方法在预测开始腹膜透析（PD）患者生存率方面的作用，并确定其与患者预后的其他已知预测因素之间的相互作用，特别是腹膜功能、残余肾功能（RRF）和血浆白蛋白。
在一项对303例开始接受PD治疗的患者进行的前瞻性单中心队列研究中记录合并症情况。使用七个疾病领域，这些领域被选择用于反映终末期肾衰竭人群中心血管疾病的主导地位，合并症在无疾病时评为“0”，有一或两种疾病时评为“1”，有三种或更多疾病时评为“2”。还评估了包含年龄在评分方法中的赖特合并症指数。每6个月测量一次RRF、血浆白蛋白和腹膜溶质转运。患者在死亡时进行截尾。
根据合并症等级的中位生存期分别为105、42和29个月（P<0.0001），精算生存曲线有良好区分。使用Cox回归，将年龄和合并症等级加入Kt/V（尿素）、溶质转运和血浆白蛋白可提高模型的预测能力。除白蛋白外，所有因素均为预后的独立预测因素。赖特合并症指数也增强了Cox模型，尽管不如单独考虑年龄和合并症时有效。在基线时，除非单独考虑糖尿病，否则RRF根据合并症情况并无差异。糖尿病患者开始时RRF较高，但在接受PD治疗6个月后与非糖尿病患者相同。否则，RRF的初始下降率在不同合并症等级中相似，尽管合并症较多的患者因早期失访导致的较高失访率可能掩盖了这些患者的早期失访情况。基线时合并症增加的患者腹膜溶质转运往往较高，χ² 13.8，P = 0.032，且在治疗过程中持续存在。
合并症对PD患者的生存有定量影响，且独立于年龄、RRF和腹膜功能。合并症似乎还与治疗开始时溶质转运增加有关，且这种情况持续存在。除糖尿病外，合并症等级对RRF丧失没有深远影响。
