Piccoli Giorgina Barbara, Cabiddu Gianfranca, Moio Maria Rita, Fois Antioco, Cao Riccardo, Molfino Ida, Kaniassi Ana, Lippi Francoise, Froger Ludivine, Pani Antonello, Biolcati Marilisa
Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy.
Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.
BMC Nephrol. 2018 Jul 9;19(1):171. doi: 10.1186/s12882-018-0948-8.
Choice of dialysis is context sensitive, explored for PD and extracorporeal dialysis, but less studied for haemodialysis (HD) and hemodiafiltration (HDF), both widely employed in Italy and France; reasons of choice and differences in prescriptions may impact on dialysis-related variables, particularly relevant in elderly, high-comorbidity patients.
The study involved two high-comorbidity in-hospital cohorts, treated in Centers with similar characteristics, in Italy (Cagliari) and France (Le Mans). All patients (204) agreed to participate. Stable cases on thrice-weekly dialysis, with at least 2 months follow-up were selected (180 patients, Males 59.4%, median age 71 years, vintage 4.3 years, Charlson index 9). Univariate and multivariate correlations between baseline data, HD-HDF, dialysis efficiency and nutritional markers were assessed.
In Le Mans HDF was mainly chosen to increase efficiency (large surface dialysers, high convective volume; 76.3% of the patients), in Cagliari to improve tolerance (smaller surfaces, lower convective volume; 59% of patients). Kt/V was similar in HD and HDF, and in both settings(median Kt/V Daugirdas 2: 1.6); in the setting of high efficiency no correlation was found between Kt/V, BMI, urea, creatinine, n-PCR and phosphate. The relationship between Kt/V and albumin was divergent: a weak consensual increase was present in Cagliari, a decrease in Le Mans, suggesting a role of albumin losses with high convective volumes. In the multivariate analysis, after adjustment for other covariates (including comorbidity and type of treatment) low albumin level < 3.5 g/dl was highly correlated with setting of study: Le Mans (OR: 7.155 (2.955-17.324)). The multivariate analysis confirmed a role of type of treatment, with higher risk of low albumin levels in HDF (OR: 3.592 (1.466-8.801)), and of comorbidity (Charlson index> = 7 (OR: 3.153 (1.311-7.582)), MIS index> = 7 (OR: 5.916 (2.457-14.241)).
The different prescriptions of HD and HDF may have similar effects on dialysis efficiency, but diverging effects on crucial nutritional markers, such as albumin levels, probably more evident in high-comorbidity populations.
透析方式的选择因具体情况而异，腹膜透析（PD）和体外透析已得到研究，但血液透析（HD）和血液透析滤过（HDF）的研究较少，而这两种方式在意大利和法国广泛应用；选择原因和处方差异可能影响与透析相关的变量，这在老年、高合并症患者中尤为重要。
该研究纳入了两个高合并症的住院队列，分别在意大利（卡利亚里）和法国（勒芒）具有相似特征的中心接受治疗。所有患者（204例）均同意参与。选择每周进行三次透析且至少有2个月随访的稳定病例（180例患者，男性占59.4%，中位年龄71岁，透析龄4.3年，Charlson指数为9）。评估了基线数据、HD - HDF、透析效率和营养指标之间的单变量和多变量相关性。
在勒芒，选择HDF主要是为了提高效率（大表面积透析器，高对流体积；76.3%的患者），在卡利亚里则是为了提高耐受性（较小表面积，较低对流体积；59%的患者）。HD和HDF中的Kt/V相似，且在两种情况下（Daugirdas 2法计算的中位Kt/V：1.6）；在高效能情况下，未发现Kt/V、BMI、尿素、肌酐、n - PCR和磷酸盐之间存在相关性。Kt/V与白蛋白之间的关系存在差异：在卡利亚里存在微弱的一致性升高，在勒芒则降低，这表明高对流体积导致白蛋白丢失起了作用。在多变量分析中，在调整其他协变量（包括合并症和治疗类型）后，白蛋白水平<3.5 g/dl与研究地点高度相关：勒芒（比值比：7.155（2.955 - 17.324））。多变量分析证实了治疗类型的作用，HDF中白蛋白水平低的风险更高（比值比：3.592（1.466 - 8.801）），以及合并症的作用（Charlson指数>=7（比值比：3.153（1.311 - 7.582）），MIS指数>=7（比值比：5.916（2.457 - 14.241））。
HD和HDF的不同处方可能对透析效率有相似影响，但对关键营养指标如白蛋白水平有不同影响，这在高合并症人群中可能更为明显。
