Isakova Tamara, Gutiérrez Orlando M, Chang Yuchiao, Shah Anand, Tamez Hector, Smith Kelsey, Thadhani Ravi, Wolf Myles
Renal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
J Am Soc Nephrol. 2009 Feb;20(2):388-96. doi: 10.1681/ASN.2008060609. Epub 2008 Dec 17.
Although hyperphosphatemia is a risk factor for mortality, there are limited data on whether therapy with phosphorus binders affects survival. We analyzed a prospective cohort study of 10,044 incident hemodialysis patients using Cox proportional hazards analyses to compare 1-yr all-cause mortality among patients who were or were not treated with phosphorus binders. We performed intention-to-treat analyses to compare patients who began treatment with phosphorus binders during the first 90 d after initiating hemodialysis (n = 3555) with those who remained untreated during that period (n = 5055). We also performed as-treated analyses that modeled phosphorus binder treatment as a time-dependent exposure. We compared survival in a subcohort of treated (n = 3186) and untreated (n = 3186) patients matched by their baseline serum phosphate levels and propensity score of receiving phosphorus binders during the first 90 d. One-year mortality was 191 deaths/1000 patient-years at risk. Treatment with phosphorus binders was independently associated with decreased mortality compared with no treatment in the intention-to-treat, as-treated, and matched analyses. The results were independent of baseline and follow-up serum phosphate levels and persisted in analyses that excluded deaths during the first 90 d of hemodialysis. In summary, treatment with phosphorus binders is independently associated with improved survival among incident hemodialysis patients. Although confirmatory studies are needed in the dialysis setting, future placebo-controlled, randomized trials of phosphorus binders might focus on predialysis patients with chronic kidney disease and normal serum phosphate levels.
尽管高磷血症是死亡的一个危险因素，但关于磷结合剂治疗是否影响生存率的数据有限。我们分析了一项对10,044例新发血液透析患者的前瞻性队列研究，使用Cox比例风险分析比较接受或未接受磷结合剂治疗的患者的1年全因死亡率。我们进行意向性分析，以比较在开始血液透析后的前90天内开始使用磷结合剂治疗的患者（n = 3555）与在此期间未接受治疗的患者（n = 5055）。我们还进行了实际治疗分析，将磷结合剂治疗建模为时间依赖性暴露。我们比较了根据基线血清磷酸盐水平和在前90天内接受磷结合剂的倾向评分匹配的治疗组（n = 3186）和未治疗组（n = 3186）患者的生存率。1年死亡率为191例死亡/1000患者-年风险。在意向性分析、实际治疗分析和匹配分析中，与未治疗相比，磷结合剂治疗与死亡率降低独立相关。结果独立于基线和随访血清磷酸盐水平，并且在排除血液透析前90天内死亡的分析中仍然成立。总之，磷结合剂治疗与新发血液透析患者生存率提高独立相关。尽管在透析环境中需要进行验证性研究，但未来关于磷结合剂的安慰剂对照、随机试验可能会聚焦于慢性肾脏病且血清磷酸盐水平正常的透析前患者。
