透析患者的败血症、血管通路与心血管疾病：美国肾脏数据系统第2波研究

Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study.

作者信息

Ishani Areef, Collins Allan J, Herzog Charles A, Foley Robert N

机构信息

Section of Nephrology, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.

出版信息

Kidney Int. 2005 Jul;68(1):311-8. doi: 10.1111/j.1523-1755.2005.00414.x.

DOI:10.1111/j.1523-1755.2005.00414.x

PMID:15954922

Abstract

BACKGROUND

Microinflammation is linked to cardiovascular disease, and is highly prevalent in dialysis patients. It is logical to postulate that septicemia, a common macroinflammatory occurrence in dialysis patients, contributes to their large burden of cardiovascular disease.

METHODS

The Dialysis Morbidity and Mortality Wave 2 was a randomly selected prospective cohort of incident dialysis patients. Admission claims data were used to define and calculate rates of septicemia or bacteremia and cardiovascular events in those with Medicare as the primary payer. Utilizing Cox proportional hazard models we determined the association between baseline access and the development of bacteremia or sepsis, and also the association between bacteremia or sepsis episodes and subsequent cardiovascular events.

RESULTS

The 2358 (59%) patients with Medicare as primary payer were older and more likely to have heart failure than those with other payers, but had similar comorbidity-adjusted mortality hazards. Rates of first septicemia, bacteremia, or either condition, were 7.0, 5.9 and 10.4 events per 100-patient years, respectively. Cox regression identified initial dialysis access as the main antecedent of septicemia or bacteremia. Hazards ratios for hemodialysis with permanent catheters, temporary catheters, and grafts were 1.95 (95% CI 1.47-2.57), 1.76 (95% CI 1.29-2.41), and 1.05 (95% CI 0.82-1.35), respectively, while that for peritoneal dialysis was 0.96 (95% CI 0.75-1.23) (reference arteriovenous fistula). After adjustment for baseline factors, septicemia or bacteremia, as a time-dependent covariate, was associated with subsequent death [hazards ratio (HR) 2.33, 95% CI 1.38-2.28], myocardial infarction (HR 1.78, 95% CI 1.38-2.28), heart failure (HR 1.64, 95% CI 1.39-1.95), peripheral vascular disease (HR 1.64, 95% CI 1.34-2.0), and stroke (HR 2.04, 95% CI 1.27-3.28).

CONCLUSION

Septicemia appears to be an important, potentially preventable, cardiovascular risk factor in dialysis patients.

摘要

背景

微炎症与心血管疾病相关，在透析患者中极为普遍。由此推测，败血症作为透析患者常见的大炎症事件，会加重其心血管疾病负担，这是合乎逻辑的。

方法

透析发病率和死亡率研究的第二波是一项对新发病透析患者进行随机选择的前瞻性队列研究。利用入院申报数据来定义和计算以医疗保险作为主要支付方的患者的败血症或菌血症发生率以及心血管事件发生率。我们使用Cox比例风险模型来确定基线血管通路与菌血症或败血症发生之间的关联，以及菌血症或败血症发作与随后心血管事件之间的关联。

结果

以医疗保险作为主要支付方的2358名（59%）患者比其他支付方的患者年龄更大，更易发生心力衰竭，但在合并症调整后的死亡风险相似。首次败血症、菌血症或两种情况的发生率分别为每100患者年7.0、5.9和10.4例事件。Cox回归确定初始透析血管通路是败血症或菌血症的主要前驱因素。使用永久性导管、临时性导管和移植物进行血液透析的风险比分别为1.95（95%可信区间1.47 - 2.57）、1.76（95%可信区间1.29 - 2.41）和1.05（95%可信区间0.82 - 1.35），而腹膜透析的风险比为0.96（95%可信区间0.75 - 1.23）（参考动静脉内瘘）。在对基线因素进行调整后，败血症或菌血症作为一个随时间变化的协变量，与随后的死亡[风险比（HR）2.33，95%可信区间1.38 - 2.28]、心肌梗死（HR 1.78，95%可信区间1.38 - 2.28）、心力衰竭（HR 1.64，95%可信区间1.39 - 1.95）、外周血管疾病（HR 1.64，95%可信区间1.34 - 2.0）和中风（HR 2.04，95%可信区间1.27 - 3.28）相关。