Arif Faisal M, Sumida Keiichi, Molnar Miklos Z, Potukuchi Praveen K, Lu Jun Ling, Hassan Fatima, Thomas Fridtjof, Siddiqui Omer A, Gyamlani Geeta G, Kalantar-Zadeh Kamyar, Kovesdy Csaba P
Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
Nephron. 2017;137(1):15-22. doi: 10.1159/000473704. Epub 2017 Apr 27.
Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear.
We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin.
A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments.
Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.
血液透析后即刻过渡阶段的死亡率极高。美国许多终末期肾病（ESRD）患者在住院环境中开始透析，但住院开始透析患者的特征以及住院血液透析过渡与死亡率的关联仍不明确。
我们研究了2007年10月至2011年9月期间转为血液透析的48261名美国退伍军人。在Cox比例风险模型中检验了住院开始血液透析与全因死亡率的关联，并对人口统计学、合并症、血管通路类型、透析前肾病护理和药物使用，以及终末期肾病前最后估计的肾小球滤过率和血红蛋白进行了调整。
共有22338名（46.3%）患者在住院环境中接受了首次血液透析治疗。住院血液透析过渡与年龄较大、存在隧道式导管、合并症负担较高以及缺乏透析前肾病护理有关。在转为血液透析后的前6个月内，共有8674名患者死亡（死亡率为405/1000患者年，95%CI为397 - 413）。住院与门诊开始血液透析与显著更高的粗全因死亡率相关，但在多变量调整后这种关联减弱。
在住院环境中转为血液透析在年龄较大、病情较重的个体以及没有透析前肾病护理且使用导管作为血管通路的患者中更为常见。需要进一步研究以确定是否可以通过针对可改变的风险因素（如及时放置血管通路或更早进行肾病转诊）的干预措施，使更高比例的患者能够在门诊诊所开始血液透析治疗。
