甲状腺功能在终末期肾病前与早期透析死亡率的关系。
Association of thyroid status prior to transition to end-stage renal disease with early dialysis mortality.
机构信息
Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, USA.
Kaiser Permanente Southern California, Department of Nephrology, Los Angeles, CA, USA.
出版信息
Nephrol Dial Transplant. 2019 Dec 1;34(12):2095-2104. doi: 10.1093/ndt/gfy289.
BACKGROUND
Advanced chronic kidney disease (CKD) patients, including those receiving dialysis, have a high prevalence of thyroid dysfunction. Although hypothyroidism is associated with higher death risk in end-stage renal disease (ESRD) patients, no studies have examined whether thyroid status in the pre-ESRD period impacts mortality after dialysis initiation.
METHODS
Among US veterans with CKD identified from the national Veterans Affairs database that transitioned to dialysis over the period from October 2007 to September 2011, we examined the association of pre-ESRD serum thyrotropin (TSH) levels averaged over the 1-year pre-dialysis ('prelude') period with all-cause mortality in the first year following dialysis initiation.
RESULTS
Among 15 335 patients in the 1-year prelude cohort, TSH levels >5.0 mIU/L were associated with higher mortality in expanded case-mix Cox models (reference: TSH 0.5-5.0 mIU/L): adjusted hazard ratio (aHR) [95% confidence interval (CI) 1.20 (1.07-1.33). Similar findings were observed for TSH >5.0 mIU/L and mortality in the 2- and 5-year cohorts: aHRs (95% CI) 1.11 (1.02-1.21) and 1.15 (1.07-1.24), respectively. Analyses of finer gradations of TSH in the 1-year prelude cohort demonstrated that incrementally higher levels >5.0 mIU/L were associated with increasingly higher mortality in expanded case-mix models (reference: TSH 0.5-3.0 mIU/L): aHRs (95% CI) 1.18 (1.04-1.33) and 1.28 (1.03-1.59) for TSH levels >5.0-10.0 mIU/L and >10.0 mIU/L, respectively. In the 2- and 5-year cohorts, mortality associations persisted most strongly for those with TSH >10.0 mIU/L, particularly after laboratory covariate adjustment.
CONCLUSIONS
Among new ESRD patients, there is a dose-dependent relationship between higher pre-ESRD TSH levels >5.0 mIU/L and post-ESRD mortality. Further studies are needed to determine the impact of TSH reduction with thyroid hormone supplementation in this population.
背景
患有慢性肾脏病（CKD）的晚期患者，包括接受透析的患者，甲状腺功能障碍的患病率很高。尽管甲状腺功能减退症与终末期肾脏疾病（ESRD）患者的死亡风险增加有关，但尚无研究探讨 ESRD 前时期的甲状腺状态是否会影响透析开始后的死亡率。
方法
我们在美国退伍军人事务部的全国退伍军人事务数据库中，确定了从 2007 年 10 月至 2011 年 9 月期间过渡到透析的 CKD 患者，在透析前的 1 年（“前奏”期）内，检查平均血清促甲状腺激素（TSH）水平与透析开始后第一年全因死亡率之间的关系。
结果
在 1 年前奏队列中的 15335 例患者中，TSH 水平>5.0 mIU/L 与扩展病例混合 Cox 模型中的更高死亡率相关（参考：TSH 0.5-5.0 mIU/L）：调整后的危险比（aHR）[95%置信区间（CI）1.20（1.07-1.33）。在 2 年和 5 年队列中也观察到了 TSH >5.0 mIU/L 与死亡率之间的类似发现：aHR（95%CI）分别为 1.11（1.02-1.21）和 1.15（1.07-1.24）。在 1 年前奏队列中对 TSH 的更精细分级分析表明，TSH 水平逐渐升高>5.0 mIU/L 与扩展病例混合模型中的死亡率逐渐升高相关（参考：TSH 0.5-3.0 mIU/L）：aHR（95%CI）分别为 1.18（1.04-1.33）和 1.28（1.03-1.59）对于 TSH 水平>5.0-10.0 mIU/L 和>10.0 mIU/L。在 2 年和 5 年队列中，对于 TSH >10.0 mIU/L 的患者，死亡率相关性最强，尤其是在实验室协变量调整后。
结论
在新的 ESRD 患者中，TSH 水平升高>5.0 mIU/L 与 ESRD 后死亡率之间存在剂量依赖性关系。需要进一步的研究来确定在该人群中使用甲状腺激素补充剂降低 TSH 的影响。
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