Lacson Eduardo, Wang Weiling, Lazarus J Michael, Hakim Raymond M
Fresenius Medical Care-North America, Waltham, MA 02451-1457, USA.
Am J Kidney Dis. 2009 Nov;54(5):912-21. doi: 10.1053/j.ajkd.2009.07.008. Epub 2009 Sep 12.
We hypothesized that a change from central venous catheters to a fistula or graft would improve short-term mortality risk in maintenance hemodialysis patients.
Prospective observational study.
SETTING & PARTICIPANTS: All maintenance in-center hemodialysis patients treated in Fresenius Medical Care, North America legacy facilities alive on January 1, 2007 with baseline laboratory data from December 2006.
Access type (fistula, catheter, or graft), determined on December 31, 2006, and monthly thereafter. Conversion from a catheter to a fistula or graft during the 4-month period from January 1 to April 30, 2007.
Mortality was tracked from May 1, 2007, to December 31, 2007. Standard and time-dependent Cox models were used to determine hazard risks (HRs) of death with and without adjustment for case-mix and laboratory values.
At baseline, 79,545 patients had 43% fistulas, 29% catheters, and 27% grafts. Mean age was 62 +/- 15 years, 54% were men, 51% were white, and 53% had diabetes. Compared with fistulas, unadjusted HRs of death were higher for grafts (1.22) and catheters (1.76; P < 0.001). In adjusted models, overall risk for grafts was decreased to 1.05 (95% limits, 1.003-1.100; P < 0.05) and approached that for fistulas consistently across multiple strata. Compared with patients who continued using a catheter, those who converted to either a graft or fistula had an HR of 0.69, whereas those who converted from a graft or fistula to a catheter had increased HRs to 2.12 (both P < 0.001). Similar trends were observed in the subset of incident patients (vintage < 90 days at study onset).
Observational design with residual confounding from unmeasured patient, facility, and treatment-related factors.
Catheters have the worst associated mortality risk. Changing from a catheter to a fistula or graft is associated with significantly improved survival. The risk for grafts approached that of fistulas, providing an alternative to prolonged catheter exposure and potentially less hazardous "bridge" toward a fistula.
我们假设，对于维持性血液透析患者，从中心静脉导管改为动静脉内瘘或移植物可降低短期死亡风险。
前瞻性观察性研究。
所有在北美费森尤斯医疗保健公司传统设施中接受维持性中心血液透析治疗的患者，于2007年1月1日存活，并提供了2006年12月的基线实验室数据。
2006年12月31日及之后每月确定的血管通路类型（动静脉内瘘、导管或移植物）。在2007年1月1日至4月30日的4个月期间从导管转换为动静脉内瘘或移植物。
从2007年5月1日至2007年12月31日追踪死亡率。使用标准和时间依赖性Cox模型确定在调整病例组合和实验室值及未调整情况下的死亡风险比（HRs）。
基线时，79,545例患者中，43%为动静脉内瘘，29%为导管，27%为移植物。平均年龄为62±15岁，54%为男性，51%为白人，53%患有糖尿病。与动静脉内瘘相比，移植物（HR = 1.22）和导管（HR = 1.76；P < 0.001）的未调整死亡风险比更高。在调整模型中，移植物的总体风险降至1.05（95%置信区间，1.003 - 1.100；P < 0.05），并且在多个分层中始终接近动静脉内瘘的风险。与继续使用导管的患者相比，转换为移植物或动静脉内瘘的患者的风险比为0.69，而从移植物或动静脉内瘘转换为导管的患者的风险比增加至2.12（均P < 0.001）。在新发病例亚组（研究开始时透析龄<90天）中观察到类似趋势。
观察性设计，存在来自未测量的患者、设施和治疗相关因素的残余混杂。
导管具有最差的相关死亡风险。从导管转换为动静脉内瘘或移植物与生存率显著提高相关。移植物的风险接近动静脉内瘘的风险，为避免长期使用导管以及为建立动静脉内瘘提供潜在危害较小的“过渡”方案提供了一种选择。
