首次发生血源性感染的透析患者的死亡风险，尤其考虑血管通路和合并症。
Risk of death after first-time blood stream infection in incident dialysis patients with specific consideration on vascular access and comorbidity.
机构信息
Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Department of Production, Research and Innovation, Region zealand, Sorø, Denmark.
出版信息
BMC Infect Dis. 2018 Dec 20;18(1):688. doi: 10.1186/s12879-018-3594-7.
BACKGROUND
The mortality following blood stream infection (BSI) and risk of subsequent BSI in relation to dialysis modality, vascular access, and other potential risk factors has received relatively little attention. Consequently, we assessed these matters in a retrospective cohort study, by use of the Danish nation-wide registries.
METHODS
Patients more than 17 years of age, who initiated dialysis between 1.1.2010 and 1.1.2014, were grouped according to their dialysis modality and vascular access. Survival was modeled in time-dependent Cox proportional hazard analyses. Potential risk factors confined by a modified Charlson comorbidity index (MCCI), were subsequently assessed in stepwise selection models.
RESULTS
At baseline, 764 patients received peritoneal dialysis (PD), and 434, 479, and 782 hemodialysis (HD) patients were dialyzed by use of arteriovenous fistulas (AVFs), tunneled catheters (TCs), and non-tunneled catheters (NTCs), respectively. We identified 1069 BSIs with an overall incidence rate of 17.7 episodes per 100 person years, and 216 BSIs occurred more than one time in the same patient. HRs of post BSI mortality relative to PD were 3.20 (95% CI 1.86-5.50; p < 0.001) with NTCs; whereas no associations were found for AVF and TC. The risk of subsequent BSIs was higher with NTCs [HR 2.29 (95% CI 1.09-4.82), p = 0.030], and no significant difference was found for AVF and TC, in relation to PD. There was an increased risk of both outcomes with TC relative to AVF [death: 1.57 (95% CI 1.07-2.29, P < 0.021); BSI: 1.78 (95% CI 1.13-2.83, P < 0.014], and risk of death was reduced in patients who changed to AVF after first-time BSI. The MCCI was significantly associated with the risk of subsequent BSI and post BSI death; however, only some of the variables contained in the index were found to be significant risk predictors when analyzed in the fitted model.
CONCLUSIONS
While NTC was the most predominant risk factor for subsequent BSI and post BSI mortality, AVF appeared protective.
背景
血流感染（BSI）后的死亡率以及与透析方式、血管通路和其他潜在危险因素相关的后续 BSI 风险，受到的关注相对较少。因此，我们使用丹麦全国性登记处，在一项回顾性队列研究中评估了这些问题。
方法
17 岁以上，2010 年 1 月 1 日至 2014 年 1 月 1 日期间开始透析的患者，根据透析方式和血管通路分组。使用时间依赖性 Cox 比例风险分析对生存情况进行建模。随后，在逐步选择模型中评估受限的改良 Charlson 合并症指数（MCCI）的潜在危险因素。
结果
基线时，764 名患者接受腹膜透析（PD），434、479 和 782 名血液透析（HD）患者分别通过动静脉瘘（AVF）、隧道导管（TC）和非隧道导管（NTC）进行透析。我们发现 1069 例 BSI，总发病率为每 100 人年 17.7 例，216 例患者在同一患者中发生 1 次以上 BSI。与 PD 相比，BSI 后死亡率的 HR 为 3.20（95%CI 1.86-5.50;p<0.001），NTC 为 3.20；而 AVF 和 TC 则无相关性。与 PD 相比，NTC 的后续 BSI 风险更高[HR 2.29（95%CI 1.09-4.82），p=0.030]，而 AVF 和 TC 则无显著差异。与 AVF 相比，TC 与两种结局的风险增加相关[死亡：1.57（95%CI 1.07-2.29，P<0.021）；BSI：1.78（95%CI 1.13-2.83，P<0.014]，首次 BSI 后改为 AVF 的患者死亡风险降低。MCCI 与随后的 BSI 和 BSI 后死亡风险显著相关；然而，当在拟合模型中分析时，指数中包含的一些变量被发现是显著的风险预测因子。
结论
虽然 NTC 是随后 BSI 和 BSI 后死亡的最主要危险因素，但 AVF 似乎具有保护作用。
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