Chen Yung-Ming, Wang Yi-Cheng, Hwang Shang-Jyh, Lin Shih-Hwa, Wu Kwan-Dun
Renal Division, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taipei, Taiwan.
Nephron. 2016;132(1):33-42. doi: 10.1159/000442168. Epub 2015 Nov 21.
There is a trend toward deferring the initiation of chronic dialysis until absolutely indicated. This strategy, however, might lead to increased uncertainties in the timing of dialysis access creation prior to dialysis onset for patients approaching end-stage renal disease (ESRD), and the impact of which on hard end points remains largely unclear. We hereby investigated the effect of varied patterns of dialysis initiation on outcomes of new-onset hemodialysis (HD) patients.
Four hundred sixty-two prospectively recruited patients were stratified into planned elective (n = 117, 25%), planned urgent (n = 65, 14%) or unplanned urgent (n = 280, 61%) starters based on the timing of access creation with respect to dialysis initiation. The outcome measures were all-cause mortality, hospitalization and access reconstruction over 2 years.
The mean estimated glomerular filtration rate (eGFR) was higher in the planned elective than in the planned urgent or unplanned urgent starters at access creation (5.3 vs. 4.4 or 4.3 ml/min/1.73 m2), but not at dialysis initiation (4.2 vs. 3.9 or 4.3 ml/min/1.73 m2). During the follow-up, the planned elective population exhibited the lowest rates of overall mortality and hospitalization, but not access reconstruction. Multivariate Cox's regression analysis showed that the planned urgent and the unplanned urgent groups, comparing to the planned elective population, displayed a greater risk of early death (hazards ratio [HR] 3.324, 95% CI 1.409-7.840; HR 2.510, 95% CI 1.177-5.355, respectively) and early hospitalization (sub-hazards ratio [SubHR] 2.238, 95% CI 1.530-3.274; SubHR 1.529, 95% CI 1.096-2.133, respectively).
Incident ESRD patients undergoing planned elective start of HD, compared to their planned or unplanned urgent counterparts, showed reduced risk of overall mortality and hospitalization in the first 2 years after commencing long-term dialysis at a mean eGFR <5 ml/min/1.73 m2.
目前存在一种趋势，即推迟慢性透析的启动，直到绝对必要时才进行。然而，对于接近终末期肾病（ESRD）的患者，这种策略可能会导致在透析开始前建立透析通路的时间增加不确定性，而其对硬性终点的影响在很大程度上仍不清楚。我们在此研究了不同透析启动模式对新开始血液透析（HD）患者结局的影响。
根据建立通路时间与透析启动时间的关系，将462例前瞻性招募的患者分为计划择期启动组（n = 117，25%）、计划紧急启动组（n = 65，14%）或非计划紧急启动组（n = 280，61%）。结局指标为2年内的全因死亡率、住院率和通路重建情况。
在建立通路时，计划择期启动组的平均估计肾小球滤过率（eGFR）高于计划紧急启动组或非计划紧急启动组（5.3 vs. 4.4或4.3 ml/min/1.73 m²），但在透析开始时并非如此（4.2 vs. 3.9或4.3 ml/min/1.73 m²）。在随访期间，计划择期启动组的总体死亡率和住院率最低，但通路重建率并非如此。多因素Cox回归分析显示，与计划择期启动组相比，计划紧急启动组和非计划紧急启动组显示出更高的早期死亡风险（风险比[HR]分别为3.324，95%CI 1.409 - 7.840；HR 2.510，95%CI 1.177 - 5.355）和早期住院风险（亚风险比[SubHR]分别为2.238，95%CI 1.530 - 3.274；SubHR 1.529，95%CI 1.096 - 2.133）。
与计划或非计划紧急启动HD的初发ESRD患者相比，平均eGFR <5 ml/min/1.73 m²的初发ESRD患者在开始长期透析后的前2年进行计划择期启动HD，显示出总体死亡率和住院率降低的风险。
