Departments of Medicine and.
Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and.
Clin J Am Soc Nephrol. 2018 May 7;13(5):746-753. doi: 10.2215/CJN.09910917. Epub 2018 Apr 19.
Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment).
The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture.
Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.
接受血液透析的患者经常会经历疼痛，并且可能特别容易受到阿片类药物相关并发症的影响。然而，评估接受血液透析的患者使用阿片类药物的风险的数据有限。
设计、地点、参与者和测量方法：使用美国肾脏数据系统，我们进行了一项队列研究，评估了阿片类药物使用（建模为随时间变化的暴露，并以标准化口服吗啡当量表示）与在 2011 年接受血液透析的 140899 名医疗保险覆盖的成年人中首次因精神状态改变、跌倒和骨折而到急诊室就诊或住院的时间之间的关联。我们根据平均每日总阿片类药物剂量（＞60mg、≤60mg 和每 60mg 剂量增量）和特定药物（每 60mg 剂量增量）评估了风险。
中位年龄为 61 岁，52%为男性，50%为白人。64%的患者接受了阿片类药物治疗，2011 年有 15658 例出现精神状态改变（15658 例）、跌倒（7646 例）或骨折（4151 例）。阿片类药物的使用与所有结局呈剂量依赖性相关：精神状态改变（较低剂量：风险比，1.28；95%置信区间，1.23 至 1.34；较高剂量：风险比，1.67；95%置信区间，1.56 至 1.78；风险比，每 60mg 增加 1.29；95%置信区间，1.26 至 1.33）、跌倒（较低剂量：风险比，1.28；95%置信区间，1.21 至 1.36；较高剂量：风险比，1.45；95%置信区间，1.31 至 1.61；风险比，每 60mg 增加 1.04；95%置信区间，1.03 至 1.05）和骨折（较低剂量：风险比，1.44；95%置信区间，1.33 至 1.56；较高剂量：风险比，1.65；95%置信区间，1.44 至 1.89；风险比，每 60mg 增加 1.04；95%置信区间，1.04 至 1.05）。所有药物与精神状态改变的风险显著增加相关，几种药物与跌倒和骨折的风险显著增加相关。
阿片类药物与血液透析患者的不良结局相关，即使在较低剂量和指南推荐使用的药物时，也存在这种风险。
