Tentori Francesca, Hunt William C, Rohrscheib Mark, Zhu Min, Stidley Christine A, Servilla Karen, Miskulin Dana, Meyer Klemens B, Bedrick Edward J, Johnson H Keith, Zager Philip G
Dialysis Clinic Inc., Health Sciences Center, University of New Mexico, Albuquerque, NM 87131, USA.
J Am Soc Nephrol. 2007 Aug;18(8):2377-84. doi: 10.1681/ASN.2006111250. Epub 2007 Jul 18.
Professional organizations have developed practice guidelines in the hope of improving clinical outcomes. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has set targets for dialysis dosage (single-pool Kt/V), hematocrit, serum albumin, calcium, phosphorus, parathyroid hormone, and BP for hemodialysis (HD) patients. Several guidelines are largely based on results from observational studies. In contrast to other parameters, BP values within the KDOQI guidelines have been associated with increased mortality. Therefore, it was postulated that having multiple parameters that satisfy the current guidelines, except those for BP, is associated with improved survival among HD patients. A retrospective analysis was conducted of incident HD patients who were treated at facilities operated by Dialysis Clinic Inc., a not-for-profit dialysis provider, between January 1, 1998, and December 31, 2004 (n = 13,792). Cox proportional hazards models were used to assess the association between satisfying guidelines and mortality. Values within guidelines for single-pool Kt/V, hematocrit, serum albumin, calcium, phosphorus, and parathyroid hormone were associated with decreased mortality (P < or = 0.0001). The largest survival benefit was found for serum albumin (hazard ratio [HR] 0.27; 95% confidence interval [CI] 0.24 to 0.31). Satisfying these six guidelines simultaneously was associated with an 89% reduction in mortality (HR 0.11; 95% CI 0.06 to 0.19]). Conversely, BP values satisfying the guideline were associated with increased mortality (HR 1.90; 95% CI 1.73 to 2.10). Because this target was largely extrapolated from the general population, a randomized, controlled trial is needed to identify the optimal BP for HD patients.
专业组织制定了实践指南，以期改善临床治疗效果。美国国家肾脏基金会的肾脏病预后质量倡议（KDOQI）为血液透析（HD）患者设定了透析剂量（单池Kt/V）、血细胞比容、血清白蛋白、钙、磷、甲状旁腺激素及血压的目标值。多项指南很大程度上基于观察性研究的结果。与其他参数不同，KDOQI指南中的血压值与死亡率增加相关。因此，有人推测，除血压外，满足当前指南的多个参数与HD患者生存率提高相关。对1998年1月1日至2004年12月31日期间在非营利性透析服务提供商透析诊所公司运营的机构接受治疗的初治HD患者进行了一项回顾性分析（n = 13,792）。采用Cox比例风险模型评估满足指南与死亡率之间的关联。单池Kt/V、血细胞比容、血清白蛋白、钙、磷及甲状旁腺激素的指南内值与死亡率降低相关（P≤0.0001）。血清白蛋白的生存获益最大（风险比[HR] 0.27；95%置信区间[CI] 0.24至0.31）。同时满足这六项指南与死亡率降低89%相关（HR 0.11；95% CI 0.06至0.19）。相反，满足指南的血压值与死亡率增加相关（HR 1.90；95% CI 1.73至2.10）。由于该目标很大程度上是从普通人群推断而来，因此需要进行一项随机对照试验来确定HD患者的最佳血压。
