新透析患者的递增式血液透析、残余肾功能与死亡风险：一项队列研究
Incremental Hemodialysis, Residual Kidney Function, and Mortality Risk in Incident Dialysis Patients: A Cohort Study.
作者信息
Obi Yoshitsugu, Streja Elani, Rhee Connie M, Ravel Vanessa, Amin Alpesh N, Cupisti Adamasco, Chen Jing, Mathew Anna T, Kovesdy Csaba P, Mehrotra Rajnish, Kalantar-Zadeh Kamyar
机构信息
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA.
Department of Medicine, University of California Irvine, Orange, CA.
出版信息
Am J Kidney Dis. 2016 Aug;68(2):256-265. doi: 10.1053/j.ajkd.2016.01.008. Epub 2016 Feb 9.
BACKGROUND
Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF.
STUDY DESIGN
A longitudinal cohort.
SETTING & PARTICIPANTS: 23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year.
PREDICTOR
Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time.
OUTCOMES
Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year.
RESULTS
Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d.
LIMITATIONS
Potential selection bias and wide CIs.
CONCLUSIONS
Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.
背景
无论患者的残余肾功能（RKF）如何，维持性血液透析通常规定每周进行三次。我们假设，在血液透析治疗开始时采用较低频率的治疗方案与更好地保留RKF相关，且不会影响具有大量RKF的患者的生存率。
研究设计
一项纵向队列研究。
设置与参与者
23645名在美国一家大型透析机构开始维持性血液透析治疗的患者（2007年1月至2010年12月），在透析的前91天（或一个季度）有可用的RKF数据，且存活超过一年。
预测因素
在过渡到透析后的前91天内，递增式（在连续>6周内常规每周两次）与传统式（每周三次）血液透析方案。
结果
在第一季度后的1年内肾尿素清除率和尿量的变化，以及第一年之后的生存率。
结果
在纳入研究的23645名患者中，51%在基线时具有较高的肾尿素清除率（≥3.0mL/min/1.73m²）。与根据基线肾尿素清除率、尿量、年龄、性别、糖尿病和中心静脉导管使用情况匹配的8068名接受传统血液透析方案的患者相比，351名接受递增式方案的患者在第二季度的肾尿素清除率和尿量分别多保留了16%（95%CI，5%-28%）和15%（95%CI，2%-30%），并在随后的几个季度中持续保持。递增式方案在基线肾尿素清除率不足（≤3.0mL/min/1.73m²）的患者中显示出较高的死亡风险（HR，1.61；95%CI，1.07-2.44），但在基线肾尿素清除率较高的患者中并非如此（HR，0.99；95%CI，0.76-1.28）。在以基线尿量600mL/d定义的亚组中结果相似。
局限性
存在潜在的选择偏倚和较宽的置信区间。
结论
在具有大量RKF的新发血液透析患者中，递增式血液透析可能是一种安全的治疗方案，并且与更好地保留RKF相关，而在RKF最低的患者中，透析第一年之后观察到较高的死亡率。需要进行临床试验来检验每周两次血液透析的安全性和有效性。
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