University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina; and.
J Am Soc Nephrol. 2018 Aug;29(8):2178-2188. doi: 10.1681/ASN.2018010004. Epub 2018 May 23.
Hospitalizations and 30-day readmissions are common in the hemodialysis population. Actionable clinical markers for near-term hospital encounters are needed to identify individuals who require swift intervention to avoid hospitalization. Aspects of volume management, such as failed target weight (i.e, estimated dry weight) achievement, are plausible modifiable indicators of impending adverse events. The short-term consequences of failed target weight achievement are not well established. Statistically deidentified data were taken from a cohort of Medicare-enrolled, prevalent hemodialysis patients treated at a large dialysis organization from 2010 to 2012. We used a retrospective cohort design with repeated intervals, each consisting of 180-day baseline, 30-day exposure assessment, and 30-day follow-up period, to estimate the associations between failed target weight achievement and the risk of 30-day emergency department visits and hospitalizations. We estimated adjusted risk differences using inverse probability of exposure weighted Kaplan-Meier methods. A total of 113,561 patients on hemodialysis contributed 788,722 study intervals to analyses. Patients who had a postdialysis weight >1.0 kg above the prescribed target weight in ≥30% (versus <30%) of exposure period treatments had a higher absolute risk (risk difference) of 30-day: emergency department visits (2.13%; 95% confidence interval, 2.00% to 2.32%); and all-cause (1.47%; 95% confidence interval, 1.34% to 1.62%), cardiovascular (0.31%; 95% confidence interval, 0.24% to 0.40%), and volume-related (0.15%; 95% confidence interval, 0.11% to 0.21%) hospitalizations. In the absence of objective measures of volume status, recurrent failure to achieve target weight is an easily identifiable clinical risk marker for impending hospital encounters among patients on hemodialysis.
住院和 30 天内再入院在血液透析人群中很常见。需要有可操作的临床指标来识别那些需要迅速干预以避免住院的个体。容量管理的各个方面，如未能达到目标体重（即估计干体重），是即将发生不良事件的合理可改变指标。未能达到目标体重的短期后果尚未得到很好的确定。从 2010 年至 2012 年，在一家大型透析机构接受治疗的医疗保险登记的普遍血液透析患者队列中，我们从统计学上确定了匿名数据。我们使用了具有重复间隔的回顾性队列设计，每个间隔包括 180 天的基线、30 天的暴露评估和 30 天的随访期，以估计未能达到目标体重与 30 天急诊就诊和住院风险之间的关系。我们使用逆概率暴露加权 Kaplan-Meier 方法估计调整后的风险差异。共有 113561 名血液透析患者为 788722 个研究间隔做出了贡献。与暴露期治疗中（<30%）有≥30%的透析后体重超过规定目标体重 1.0 公斤以上的患者相比，他们的 30 天绝对风险（风险差异）更高：急诊就诊（2.13%；95%置信区间，2.00%至 2.32%）；全因（1.47%；95%置信区间，1.34%至 1.62%）、心血管（0.31%；95%置信区间，0.24%至 0.40%）和容量相关（0.15%；95%置信区间，0.11%至 0.21%）住院治疗。在没有容量状态的客观指标的情况下，未能反复达到目标体重是血液透析患者即将发生医院就诊的一个易于识别的临床风险标志物。
