检测透析患者中的高风险慢性肾脏病-矿物质和骨异常表型：一项历史队列研究。

Detecting high-risk chronic kidney disease-mineral bone disorder phenotypes among patients on dialysis: a historical cohort study.

机构信息

Care Value Advanced Analytics, Fresenius Medical Care Italia, Palazzo Pignano, Cremona, Italy.

Fresenius Medical Care Italia, Bad Homburg v.d. Hesse, Germany.

出版信息

Nephrol Dial Transplant. 2019 Apr 1;34(4):682-691. doi: 10.1093/ndt/gfy273.

DOI:10.1093/ndt/gfy273

PMID:30165528

Abstract

BACKGROUND

The clinical management of chronic kidney disease-mineral bone disorder (CKD-MBD) remains extremely challenging, partially due to difficulties in defining high-risk phenotypes based on serum biomarkers. We evaluated the prevalence and outcomes of 27 mutually exclusive CKD-MBD phenotypes in a large, multi-national cohort of chronic dialysis patients over a 5-year follow-up study.

METHODS

In this historical cohort study, we enrolled all haemodialysis patients registered in EuCliD® on 1 July 2011 across 28 Europe, the Middle East and Africa (EMEA) and South American countries. We created 27 mutually exclusive phenotypes based on combinations of serum parathyroid hormone (PTH), phosphorus (P) and calcium (Ca) 6-month averages (L, low; T, target; H, high). We tested the association between CKD-MBD phenotypes and 5-year mortality and hospitalization risk by outcome risk score-adjusted proportional hazard regression.

RESULTS

We enrolled 35 721 eligible patients. Eastern European and South American countries generally achieved poorer CKD-MBD control when compared with Western European countries (prevalence ratio: 0.79; P < 0.001). There were 15 795 deaths [126.7 deaths/1000 person-years; 95% confidence interval (CI) 124.7-128.7]; 18 014 had at least one hospitalization (203.9 hospitalizations/1000 person-years; 95% CI 201.0-206.9); the incidence of the composite endpoint was 280.0 events/1000 person-years (95% CI 276.6-283.5). In the fully adjusted model, relative mortality risk ranged from hazard ratio (HR) = 1.07 (PTH/Ca/P: TLT) to HR = 1.59 (PTH/Ca/P: LTL), whereas the relative composite endpoint risk ranged from HR = 1.07 (PTH/Ca/P: TTH) to HR = 1.36 (PTH/Ca/P: LTL).

CONCLUSION

We identified several CKD-MBD phenotypes associated with reduced hospitalization-free survival and increased mortality. Ranking of relative risk estimates or excess events concurs in informing healthcare priority setting.

摘要

背景

慢性肾脏病-矿物质和骨异常（CKD-MBD）的临床管理仍然极具挑战性，部分原因是基于血清生物标志物定义高危表型存在困难。我们在一项为期 5 年的随访研究中，评估了 27 种相互排斥的 CKD-MBD 表型在大型跨国慢性透析患者队列中的患病率和结局。

方法

在这项历史性队列研究中，我们纳入了 2011 年 7 月 1 日在欧洲、中东和非洲（EMEA）和南美 28 个国家登记的所有血液透析患者。我们根据甲状旁腺激素（PTH）、磷（P）和钙（Ca）6 个月平均值（L，低；T，靶；H，高）的组合创建了 27 种相互排斥的表型。我们通过结局风险评分调整的比例风险回归检验 CKD-MBD 表型与 5 年死亡率和住院风险之间的关联。

结果

我们纳入了 35721 名合格患者。与西欧国家相比，东欧和南美国家的 CKD-MBD 控制情况普遍较差（患病率比：0.79；P<0.001）。共有 15795 人死亡[126.7 例/1000 人年；95%置信区间（CI）124.7-128.7]；18014 人至少有一次住院（203.9 例/1000 人年；95%CI 201.0-206.9）；复合终点的发生率为 280.0 例/1000 人年（95%CI 276.6-283.5）。在完全调整模型中，相对死亡风险范围从风险比（HR）=1.07（PTH/Ca/P：TLT）到 HR=1.59（PTH/Ca/P：LTL），而复合终点的相对风险范围从 HR=1.07（PTH/Ca/P：TTH）到 HR=1.36（PTH/Ca/P：LTL）。