Rivara Matthew B, Soohoo Melissa, Streja Elani, Molnar Miklos Z, Rhee Connie M, Cheung Alfred K, Katz Ronit, Arah Onyebuchi A, Nissenson Allen R, Himmelfarb Jonathan, Kalantar-Zadeh Kamyar, Mehrotra Rajnish
Department of Medicine, Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington;
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California;
Clin J Am Soc Nephrol. 2016 Feb 5;11(2):298-307. doi: 10.2215/CJN.06570615. Epub 2016 Jan 4.
In individuals undergoing in-center hemodialysis (HD), use of central venous catheters (CVCs) is associated with worse clinical outcomes compared with use of arteriovenous access. However, it is unclear whether a similar difference in risk by vascular access type is present in patients undergoing home HD.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our study examined the associations of vascular access type with all-cause mortality, hospitalization, and transfer to in-center HD in patients who initiated home HD from 2007 to 2011 in 464 facilities in 43 states in the United States. Patients were followed through December 31, 2011. Data were analyzed using competing risks hazards regression, with vascular access type at the start of home HD as the primary exposure in a propensity score-matched cohort (1052 patients; 526 with CVC and 526 with arteriovenous access).
Over a median follow-up of 312 days, 110 patients died, 604 had at least one hospitalization, and 202 transferred to in-center hemodialysis. Compared with arteriovenous access use, CVC use was associated with higher risk for mortality (hazard ratio, 1.73; 95% confidence interval, 1.18 to 2.54) and hospitalization (hazard ratio, 1.19; 95% confidence interval, 1.02 to 1.39). CVC use was not associated with increased risk for transfer to in-center HD. The results of analyses in the entire unmatched cohort (2481 patients), with vascular access type modeled as a baseline exposure at start of home HD or a time-varying exposure, were similar. Analyses among a propensity score-matched cohort of patients undergoing in-center HD also showed similar risks for death and hospitalization with use of CVCs.
In a large cohort of patients on home HD, CVC use was associated with higher risk for mortality and hospitalization. Additional studies are needed to identify interventions which may reduce risk associated with use of CVCs among patients undergoing home HD.
在接受中心血液透析（HD）的个体中，与使用动静脉通路相比，使用中心静脉导管（CVC）与更差的临床结局相关。然而，对于接受家庭血液透析的患者，血管通路类型在风险方面是否存在类似差异尚不清楚。
设计、地点、参与者及测量方法：我们的研究调查了2007年至2011年在美国43个州的464个机构开始接受家庭血液透析的患者中，血管通路类型与全因死亡率、住院率以及转至中心血液透析之间的关联。对患者随访至2011年12月31日。使用竞争风险危害回归分析数据，在倾向评分匹配队列（1052例患者；526例使用CVC，526例使用动静脉通路）中，将家庭血液透析开始时的血管通路类型作为主要暴露因素。
在中位随访312天期间，110例患者死亡，604例至少住院一次，202例转至中心血液透析。与使用动静脉通路相比，使用CVC与更高的死亡风险（风险比，1.73；95%置信区间，1.18至2.54）和住院风险（风险比，1.19；95%置信区间，1.02至1.39）相关。使用CVC与转至中心血液透析的风险增加无关。在整个未匹配队列（2481例患者）中进行分析的结果相似，将血管通路类型建模为家庭血液透析开始时的基线暴露或随时间变化的暴露。在接受中心血液透析的倾向评分匹配队列患者中进行的分析也显示，使用CVC时死亡和住院风险相似。
在一大群接受家庭血液透析的患者中，使用CVC与更高的死亡风险和住院风险相关。需要进一步研究以确定可能降低接受家庭血液透析患者使用CVC相关风险的干预措施。
