Polkinghorne Kevan R, McDonald Stephen P, Atkins Robert C, Kerr Peter G
Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.
J Am Soc Nephrol. 2004 Feb;15(2):477-86. doi: 10.1097/01.asn.0000109668.05157.05.
The native arteriovenous fistula (AVF) is the preferred vascular access because of its longevity and its lower rates of infection and intervention. Recent studies suggest that the AVF may offer a survival advantage. Because these data were derived from observational studies, they are prone to potential bias. The use of propensity scores offers an additional method to reduce bias resulting from nonrandomized treatment assignment. Adult (age 18 yr or more) patients who commenced hemodialysis in Australia and New Zealand on April 1, 1999, until March 31, 2002, were studied by using the Australian and New Zealand Dialysis and Transplant Association (ANZDATA) Registry. Cox regression was used to determine the effect of access type on total mortality. Propensity scores were calculated and used both as a controlling variable in the multivariable model and to construct matched cohorts. The catheter analysis was stratified by dialysis duration at entry to ANZDATA to satisfy the proportional-hazard assumption. There were 612 deaths in 3749 patients (median follow-up, 1.07 yr). After adjustment for confounding factors and propensity scores, catheter use was predictive of mortality. Patients with arteriovenous grafts (AVG) also had a significantly increased risk of death. Effect estimates were also consistent in the smaller propensity score-matched cohorts. Both AVG and catheter use in incident hemodialysis patients are associated with significant excess of total mortality. Reducing catheter use and increasing the proportion of patients commencing hemodialysis with a mature AVF remain important clinical objectives.
自体动静脉内瘘（AVF）因其使用寿命长、感染率和干预率低，是首选的血管通路。最近的研究表明，AVF可能具有生存优势。由于这些数据来自观察性研究，容易产生潜在偏差。使用倾向评分提供了一种额外的方法来减少非随机治疗分配导致的偏差。对1999年4月1日至2002年3月31日在澳大利亚和新西兰开始进行血液透析的成年（18岁及以上）患者，利用澳大利亚和新西兰透析与移植协会（ANZDATA）登记处的数据进行了研究。采用Cox回归来确定通路类型对总死亡率的影响。计算倾向评分，并将其用作多变量模型中的控制变量以及构建匹配队列。对导管的分析根据进入ANZDATA时的透析持续时间进行分层，以满足比例风险假设。3749例患者中有612例死亡（中位随访时间为1.07年）。在对混杂因素和倾向评分进行调整后，使用导管可预测死亡率。使用动静脉移植物（AVG）的患者死亡风险也显著增加。在较小的倾向评分匹配队列中，效应估计也一致。新发血液透析患者使用AVG和导管均与总死亡率显著增加相关。减少导管的使用以及增加开始血液透析时使用成熟AVF的患者比例仍然是重要的临床目标。
