Imamović Goran, Hrvačević Rajko, Kapun Sonja, Marcelli Daniele, Bayh Inga, Grassmann Aileen, Scatizzi Laura, Maslovarić Jelena, Canaud Bernard
Fresenius Medical Care, Sarajevo, Bosnia and Herzegovina,
Int Urol Nephrol. 2014 Jun;46(6):1191-200. doi: 10.1007/s11255-013-0526-8. Epub 2013 Sep 21.
Hemodiafiltration is becoming a preferred treatment modality for dialysis patients in many countries. The volume of substitution fluid delivered has been indicated as an independent mortality risk factor. The aim of this study is to compare patient survival on three different treatment modalities: high-flux hemodialysis, low-volume online HDF (oHDF) and high-volume oHDF.
Incident hemodialysis and oHDF patients treated in 13 NephroCare centers in Bosnia and Herzegovina, Serbia and Slovenia between January 1, 2007, and December 31, 2011, were included in this epidemiological cohort study. High-volume oHDF was defined as substitution volume higher than the median substitution volume infused, otherwise low-volume. Main predictor was treatment modality at baseline and in time-dependent model. Other predictors were age, gender, diabetes mellitus, cerebrovascular accident, arrhythmia, hemoglobin and C-reactive protein.
Four hundred and forty-two patients were included in the study. Median substitution fluid volume was 20.4 L. Mean difference between the oHDF groups in substitution fluid volume was 8.3 ± 5.2 L [95 % confidence intervals (95 % CI) 7.1-9.5, p < 0.0001]. The unadjusted hazard ratios (HR) with 95 % CI compared to high-flux HD were 0.87 (0.5-1.5) for low-volume oHDF and 0.29 (0.13-0.63) for high-volume oHDF. After the adjustment for covariates, the HR for patients on low-volume oHDF remained statistically insignificant compared to high-flux HD (0.84; 95 % CI 0.46-1.53), while patients on high-volume oHDF showed a marked and significantly lower HR (0.29; 95 % CI 0.13-0.68) than patients on high-flux HD in baseline model. While this effect failed to reach significance in the time-dependent model (HR 0.477; 95 % CI 0.196-1.161), possibly due to an inadequate sample size here, the consistency of results in both models supports the robustness of the findings. After switching from high-flux hemodialysis to oHDF, mean hemoglobin and albumin levels did not change significantly. Mean erythropoietin resistance index (ERI) and erythropoiesis stimulating agents (ESA) consumption decreased significantly (p = 0.02, p = 0.03, respectively).
The median substitution volume used in these three countries for post-dilutional oHDF is 20.4 L. oHDF is associated with significant reductions in ERI and ESA consumption. Only high-volume oHDF is associated with improved survival compared to high-flux hemodialysis.
血液透析滤过在许多国家正成为透析患者首选的治疗方式。置换液的输送量已被表明是一个独立的死亡风险因素。本研究的目的是比较三种不同治疗方式下患者的生存率：高通量血液透析、低容量在线血液透析滤过（oHDF）和高容量oHDF。
纳入2007年1月1日至2011年12月31日期间在波斯尼亚和黑塞哥维那、塞尔维亚和斯洛文尼亚的13个肾康中心接受治疗的初诊血液透析和oHDF患者，进行这项流行病学队列研究。高容量oHDF定义为置换量高于输注置换量中位数，否则为低容量。主要预测因素是基线时的治疗方式以及时间依赖性模型中的治疗方式。其他预测因素包括年龄、性别、糖尿病、脑血管意外、心律失常、血红蛋白和C反应蛋白。
442名患者纳入研究。置换液体积中位数为20.4L。oHDF组间置换液体积的平均差异为8.3±5.2L[95%置信区间（95%CI）7.1 - 9.5，p<0.0001]。与高通量血液透析相比，低容量oHDF的未调整风险比（HR）及95%CI为0.87（0.5 - 1.5），高容量oHDF为0.29（0.13 - 0.63）。在对协变量进行调整后，与高通量血液透析相比，低容量oHDF患者的HR在统计学上仍无显著差异（0.84；95%CI 0.46 - 1.53），而在基线模型中，高容量oHDF患者的HR明显低于高通量血液透析患者（0.29；95%CI 0.13 - 0.68）。虽然在时间依赖性模型中这种效果未达到显著水平（HR 0.477；95%CI 0.196 - 1.161），可能是由于此处样本量不足，但两个模型结果的一致性支持了研究结果的稳健性。从高通量血液透析转换为oHDF后，平均血红蛋白和白蛋白水平无显著变化。平均促红细胞生成素抵抗指数（ERI）和促红细胞生成刺激剂（ESA）的消耗量显著降低（分别为p = 0.02，p = 0.03）。
这三个国家用于后置式oHDF的置换量中位数为20.4L。oHDF与ERI和ESA消耗量的显著降低相关。与高通量血液透析相比，只有高容量oHDF与生存率提高相关。
