Department of Medicine, Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 21 Carlton Street, Unit 1405, Toronto, ON, Canada.
BMC Nephrol. 2012 Jul 30;13:72. doi: 10.1186/1471-2369-13-72.
Central venous catheters (CVCs) are associated with early mortality in dialysis patients. However, some patients progress to end stage renal disease after an acute illness, prior to reaching an estimated glomerular filtration rate (eGFR) at which one would expect to establish alternative access (fistula/peritoneal dialysis catheter). The purpose of this study was to determine if exclusion of this "acute start" patient group alters the association between CVCs and mortality.
We conducted a retrospective cohort study of 406 incident dialysis patients from 1 Jan 2006 to 31 Dec 2009. Patients were classified as acute starts if 1) the eGFR was >25 ml/min/1.73 m2, ≤ 3 months prior to dialysis initiation and declined after an acute event (n = 45), or 2) in those without prior eGFR measurements, there was no supporting evidence of chronic kidney disease on history or imaging (n = 12). Remaining patients were classified as chronic start (n = 349).
98 % and 52 % of acute and chronic starts initiated dialysis with a CVC. There were 148 deaths. The adjusted mortality hazard ratio (HR) for acute vs. chronic start patients was 1.84, (95 % CI [1.19-2.85]). The adjusted mortality HR for patients dialyzing with a CVC compared to alternative access was 1.19 (95 % CI [0.80-1.77]). After excluding acute start patients, the adjusted HR fell to 1.03 (95 % CI [0.67-1.57]).
A significant proportion of early dialysis mortality occurs after an acute start. Exclusion of this population attenuates the mortality risk associated with CVCs.
中心静脉导管（CVC）与透析患者的早期死亡率相关。然而，一些患者在达到预期建立替代通路（瘘管/腹膜透析导管）的肾小球滤过率（eGFR）之前，会因急性疾病进展至终末期肾病。本研究旨在确定排除该“急性起始”患者群体是否会改变 CVC 与死亡率之间的关联。
我们对 2006 年 1 月 1 日至 2009 年 12 月 31 日期间的 406 例新透析患者进行了回顾性队列研究。如果患者 1）eGFR＞25 ml/min/1.73 m2，且在透析开始前 3 个月内下降，并在急性事件后下降（n=45），或 2）在没有既往 eGFR 测量的患者中，病史或影像学检查无慢性肾脏病的支持证据（n=12），则将其归类为急性起始。其余患者被归类为慢性起始（n=349）。
98%和 52%的急性和慢性起始患者均使用 CVC 开始透析。共有 148 人死亡。急性与慢性起始患者的调整死亡率风险比（HR）为 1.84（95%CI[1.19-2.85]）。与替代通路相比，使用 CVC 透析的患者的调整死亡率 HR 为 1.19（95%CI[0.80-1.77]）。排除急性起始患者后，调整后的 HR 降至 1.03（95%CI[0.67-1.57]）。
早期透析死亡率的很大一部分发生在急性起始后。排除该人群可降低与 CVC 相关的死亡风险。
