Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN 55404, USA.
J Am Soc Nephrol. 2012 May;23(5):895-904. doi: 10.1681/ASN.2011080761. Epub 2012 Feb 23.
Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemodialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78-0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78-1.09) for cardiovascular disease, 1.13 (95% CI, 0.84-1.53) for infection, 0.63 (95% CI, 0.41-0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81-1.37) for other specified cause, and 0.59 (95% CI, 0.44-0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis associates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.
频繁的血液透析可改善心血管替代指标和生活质量指标，但对生存率的影响尚不清楚。我们采用匹配队列设计，评估了 2005 年至 2008 年间每日家庭血液透析和每周三次中心血液透析患者的相对死亡率。我们从美国肾脏数据系统数据库的流行人群中匹配了 1873 名家庭血液透析患者和 9365 名中心患者（即 1:5 比例）。匹配变量包括随访的首次日期、人口统计学特征和疾病严重程度的衡量标准。家庭血液透析患者和中心血液透析患者的死亡累积发生率分别为 19.2%和 21.7%。在意向治疗分析中，家庭血液透析与中心血液透析相比，全因死亡率降低了 13%（风险比 [HR]，0.87；95%置信区间 [95%CI]，0.78-0.97）。特定原因死亡率的 HR 分别为心血管疾病 0.92（95%CI，0.78-1.09）、感染 1.13（95%CI，0.84-1.53）、恶病质/透析退出 0.63（95%CI，0.41-0.95）、其他特定原因 1.06（95%CI，0.81-1.37）和未知原因 0.59（95%CI，0.44-0.79）。采用治疗分析的结果相似。在亚组分析中，我们未发现治疗效果存在统计学显著的异质性证据。总之，这些数据表明，与每周三次中心血液透析相比，每日家庭血液透析与生存率的适度改善相关。持续监测应加强对死亡率原因的推断，并确定治疗效果是否在整个透析人群中均匀。
