血糖控制改变糖尿病初治透析患者中血液透析与腹膜透析之间死亡率风险的差异：韩国一项全国性前瞻性队列研究的结果
Glycemic Control Modifies Difference in Mortality Risk Between Hemodialysis and Peritoneal Dialysis in Incident Dialysis Patients With Diabetes: Results From a Nationwide Prospective Cohort in Korea.
作者信息
Lee Mi Jung, Kwon Young Eun, Park Kyoung Sook, Kee Youn Kyung, Yoon Chang-Yun, Han In Mee, Han Seung Gyu, Oh Hyung Jung, Park Jung Tak, Han Seung Hyeok, Yoo Tae-Hyun, Kim Yong-Lim, Kim Yon Su, Yang Chul Woo, Kim Nam-Ho, Kang Shin-Wook
机构信息
From the Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam-si (MJL); Department of Internal Medicine (MJL, YEK, KSP, YKK, C-YY, IMH, SGH, HJO, JTP, SHH, T-HY, S-WK); Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul (T-HY, S-WK); Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu (Y-LK); Department of Internal Medicine, Seoul National University College of Medicine (YSK); Department of Internal Medicine, Catholic University of Korea College of Medicine, Seoul (CWY); Department of Internal Medicine, Chonnam National University Medical School, Gwangju (N-HK); and Clinical Research Centre for End-Stage Renal Disease, Daegu, Korea (Y-LK, YSK, CWY, N-HK, S-WK).
出版信息
Medicine (Baltimore). 2016 Mar;95(11):e3118. doi: 10.1097/MD.0000000000003118.
Although numerous studies have tried to elucidate the best dialysis modality in end-stage renal disease patients with diabetes, results were inconsistent and varied with the baseline characteristics of patients. Furthermore, none of the previous studies on diabetic dialysis patients accounted for the impact of glycemic control. We explored whether glycemic control had modifying effect on mortality between hemodialysis (HD) and peritoneal dialysis (PD) in incident dialysis patients with diabetes. A total of 902 diabetic patients who started dialysis between August 2008 and December 2013 were included from a nationwide prospective cohort in Korea. Based on the interaction analysis between hemoglobin A1c (HbA1c) and dialysis modalities for patient survival (P for interaction = 0.004), subjects were stratified into good and poor glycemic control groups (HbA1c< or ≥8.0%). Differences in survival rates according to dialysis modalities were ascertained in each glycemic control group after propensity score matching. During a median follow-up duration of 28 months, the relative risk of death was significantly lower in PD compared with HD in the whole cohort and unmatched patients (whole cohort, hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.47-0.90, P = 0.01; patients with available HbA1c [n = 773], HR = 0.64, 95% CI = 0.46-0.91, P = 0.01). In the good glycemic control group, there was a significant survival advantage of PD (HbA1c <8.0%, HR = 0.59, 95% CI = 0.37-0.94, P = 0.03). However, there was no significant difference in survival rates between PD and HD in the poor glycemic control group (HbA1c ≥8.0%, HR = 1.21, 95% CI = 0.46-2.76, P = 0.80). This study demonstrated that the degree of glycemic control modified the mortality risk between dialysis modalities, suggesting that glycemic control might partly contribute to better survival of PD in incident dialysis patients with diabetes.
尽管众多研究试图阐明糖尿病终末期肾病患者的最佳透析方式，但结果并不一致，且因患者的基线特征而异。此外，既往关于糖尿病透析患者的研究均未考虑血糖控制的影响。我们探讨了血糖控制对新发糖尿病透析患者血液透析（HD）和腹膜透析（PD）死亡率是否有调节作用。从韩国一项全国性前瞻性队列中纳入了2008年8月至2013年12月开始透析的902例糖尿病患者。基于糖化血红蛋白（HbA1c）与透析方式对患者生存的交互分析（交互作用P = 0.004），将受试者分为血糖控制良好组和血糖控制不佳组（HbA1c <或≥8.0%）。在倾向得分匹配后，确定各血糖控制组中不同透析方式的生存率差异。在中位随访28个月期间，整个队列和未匹配患者中，PD组的相对死亡风险显著低于HD组（整个队列，风险比[HR] = 0.65，95%置信区间[CI] = 0.47 - 0.90，P = 0.01；有可用HbA1c的患者[n = 773]，HR = 0.64，95% CI = 0.46 - 0.91，P = 0.01）。在血糖控制良好组中，PD有显著的生存优势（HbA1c <8.0%，HR = 0.59，95% CI = 0.37 - 0.94，P = 0.03）。然而，在血糖控制不佳组中，PD和HD的生存率无显著差异（HbA1c≥8.0%，HR = 1.21，95% CI = 0.46 - 2.76，P = 0.80）。本研究表明，血糖控制程度改变了透析方式之间的死亡风险，提示血糖控制可能部分有助于新发糖尿病透析患者中PD患者更好的生存。
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