Collins A J, Hanson G, Umen A, Kjellstrand C, Keshaviah P
Regional Kidney Disease Program, Hennepin County Medical Center, Minneapolis, MN 55415.
Am J Kidney Dis. 1990 May;15(5):422-32. doi: 10.1016/s0272-6386(12)70360-8.
Patient survival on hemodialysis has previously been shown to be associated with the presence of comorbid conditions on entrance. Significant comorbid conditions are atherosclerotic heart disease (ASHD), cerebral vascular disease (CVD), nonskin malignancies, chronic obstructive pulmonary disease, diabetes mellitus, and age on entrance to dialysis. Changes in annual mortality have been noted in the United States and at the Regional Kidney Disease Program. The increase in annual mortality was analyzed to determine the impact of risk factors during the time intervals 1976 to 1982 and 1983 to 1987. Patients with no major risk factors have longer survival rates and lower deaths per 1,000 treatment-months from 1983 to 1987 compared with 1976 to 1982. Diabetics have survival rates and deaths per 1,000 treatment-months that are comparable up to age 75. However, over age 75, diabetics have lower survival rates and higher death rates. The presence of comorbid conditions in the diabetic group is high and may account for the increased death rate. The percent of diabetics entering the program has increased from 29% to 48% over the intervals. Nondiabetics with comorbid conditions on entrance had higher deaths per 1,000 treatment-months from 1983 to 1987 compared with 1976 to 1982 across all age categories. Risk factor analysis shows that nondiabetics with major risks are entering with increasing numbers and continuation of comorbid conditions that impact death rates. Peripheral vascular disease, originally not significantly associated with death on dialysis, has dramatically increased from 18% to 60% in nondiabetics with comorbid conditions. In the patients over age 60 with comorbid conditions, 75% of patients now entering dialysis have peripheral vascular disease (PVD). In summary, major shifts in the hemodialysis population have occurred. Diabetics entering dialysis now account for almost 50% of all patients, with the older group having more comorbid conditions. This change alone would increase the annual mortality rate. Patients with comorbid conditions now enter with a higher prevalence of multiple comorbid conditions, which would increase the annual mortality rate. Nondiabetics without comorbid conditions now have better survival across all age categories compared with the previous data. PVD, with its current high prevalence, needs to be reevaluated as a significant risk factor for death on hemodialysis. Therefore, the increase in the annual gross mortality rate is highly predicted based on the change in the diabetic population and the increase in single and multiple comorbid conditions in the nondiabetic population.
此前已表明，接受血液透析患者的生存率与开始透析时并存疾病的存在情况相关。主要的并存疾病包括动脉粥样硬化性心脏病（ASHD）、脑血管疾病（CVD）、非皮肤恶性肿瘤、慢性阻塞性肺疾病、糖尿病以及开始透析时的年龄。在美国和地区肾脏疾病项目中已注意到年死亡率的变化。对1976年至1982年以及1983年至1987年这两个时间段内风险因素的影响进行了年死亡率增加情况的分析。与1976年至1982年相比，1983年至1987年期间没有主要风险因素的患者生存率更高，每1000个治疗月的死亡人数更低。糖尿病患者在75岁之前每1000个治疗月的生存率和死亡人数相当。然而，75岁以上的糖尿病患者生存率较低，死亡率较高。糖尿病组中并存疾病的发生率较高，这可能是死亡率增加的原因。在这两个时间段内，进入该项目的糖尿病患者比例已从29%增至48%。与1976年至1982年相比，1983年至1987年期间开始透析时患有并存疾病的非糖尿病患者每1000个治疗月的死亡人数更高，涵盖所有年龄类别。风险因素分析表明，有主要风险的非糖尿病患者人数不断增加，且并存疾病持续存在，影响死亡率。外周血管疾病原本与透析死亡无显著关联，在患有并存疾病的非糖尿病患者中已从18%急剧增至60%。在60岁以上患有并存疾病的患者中，现在开始透析的患者有75%患有外周血管疾病（PVD）。总之，血液透析人群发生了重大变化。现在开始透析的糖尿病患者几乎占所有患者的50%，年龄较大的群体并存疾病更多。仅这一变化就会增加年死亡率。现在开始透析时患有并存疾病的患者多种并存疾病的患病率更高，这也会增加年死亡率。与之前的数据相比，现在没有并存疾病的非糖尿病患者在所有年龄类别中的生存率都更高。外周血管疾病目前患病率很高，需要重新评估其作为血液透析死亡的重要风险因素。因此，基于糖尿病患者群体的变化以及非糖尿病患者群体中单一和多种并存疾病的增加，可以高度预测年总死亡率会上升。
