Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
Am J Kidney Dis. 2019 Mar;73(3):324-331. doi: 10.1053/j.ajkd.2018.09.011. Epub 2018 Nov 16.
RATIONALE & OBJECTIVE: Atrial fibrillation (AF) is common in patients with kidney failure treated by maintenance dialysis. Whether the incidence of AF differs between patients receiving hemodialysis and peritoneal dialysis is uncertain.
Retrospective cohort study.
SETTING & PARTICIPANTS: Using the US Renal Data System, we identified older patients (≥67 years) with Medicare Parts A and B who initiated dialysis therapy (1996-2011) without a diagnosis of AF during the prior 2 years.
Dialysis modality at incident end-stage renal disease (ESRD) and maintained for at least 90 days.
Patients were followed up for 36 months or less for a new diagnosis of AF.
Time-to-event analysis using multivariable Cox proportional hazards regression to estimate cause-specific HRs while censoring at modality switch, kidney transplantation, or death.
Overall, 271,722 older patients were eligible; 17,487 (6.9%) were treated with peritoneal dialysis, and 254,235 (93.1%), with hemodialysis, at the onset of ESRD. During 406,225 person-years of follow-up, 69,705 patients had AF newly diagnosed. Because the proportionality assumption was violated, we introduced an interaction term between time (first 90 days vs thereafter) and modality. The AF incidence during the first 90 days was 187/1,000 person-years on peritoneal dialysis therapy and 372/1,000 person-years on hemodialysis therapy. Patients on peritoneal dialysis therapy had an adjusted 39% (95% CI, 34%-43%) lower incidence of AF than those on hemodialysis therapy. From day 91 onward, AF incidence was ∼140/1,000 person-years with no major difference between modalities.
Residual confounding from unobserved differences between exposure groups; ascertainment of AF from billing claims; study of first modality may not generalize to patients switching modalities; uncertain generalizability to younger patients.
Although patients initiating dialysis therapy using peritoneal dialysis had a lower AF incidence during the first 90 days of ESRD, there was no major difference in AF incidence thereafter. The value of interventions to reduce the early excess AF risk in patients receiving hemodialysis may warrant further study.
在接受维持性透析治疗的肾衰竭患者中，心房颤动（AF）很常见。接受血液透析和腹膜透析治疗的患者AF 发生率是否存在差异尚不确定。
回顾性队列研究。
我们利用美国肾脏数据系统，确定了年龄在 67 岁及以上、参加 Medicare 计划 A 和 B、在过去 2 年内没有 AF 诊断的患者，这些患者在 1996 年至 2011 年期间开始透析治疗（无 AF 诊断）。
终末期肾病（ESRD）时开始的透析方式，并至少维持 90 天。
患者在随访 36 个月或更短时间内，新诊断为 AF。
采用多变量 Cox 比例风险回归进行时间事件分析，在治疗方式转换、肾移植或死亡时进行校正。
共有 271722 名年龄较大的患者符合条件；17487 名（6.9%）患者接受腹膜透析治疗，254235 名（93.1%）患者接受血液透析治疗。在 406225 人年的随访期间，有 69705 名患者新诊断为 AF。由于违反了比例假设，我们引入了时间（前 90 天与之后）和治疗方式之间的交互项。在腹膜透析治疗的前 90 天内，AF 的发病率为 187/1000 人年，而血液透析治疗的发病率为 372/1000 人年。与血液透析治疗相比，腹膜透析治疗患者的 AF 发病率低 39%（95%CI，34%-43%）。从第 91 天开始，AF 的发病率约为 140/1000 人年，两种治疗方式之间没有明显差异。
由于暴露组之间未观察到的差异导致的残余混杂；从计费索赔中确定 AF；对首次治疗方式的研究可能不适用于转换治疗方式的患者；对年轻患者的适用性不确定。
尽管开始透析治疗时使用腹膜透析的患者在 ESRD 的前 90 天内 AF 发生率较低，但此后 AF 发生率无显著差异。进一步研究减少血液透析患者早期过度 AF 风险的干预措施的价值可能是必要的。
