Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, Japan.
Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo, Japan.
PLoS One. 2019 Feb 28;14(2):e0213105. doi: 10.1371/journal.pone.0213105. eCollection 2019.
Some clinicians keep patients in stage 5 chronic kidney disease (CKD) without hemodialysis for a while. This study investigated whether previously-initiated hemodialysis in stage 5 CKD patients may become a prognostic factor for in-hospital mortality due to pneumonia.
Patient data were obtained from the multi-institutional diagnosis procedure combination database between April 1, 2012 and March 31, 2016. The patients had records of pneumonia as both trigger and major diagnoses and records of end stage renal disease (ESRD) or stage 5 CKD as a comorbidity or other diagnoses on admission and aged 18 years or older. The following factors were adjusted: age, sex, body mass index, Barthel index, orientation disturbance, arterial oxygen saturation, systolic blood pressure, C-reactive protein level or the extent of consolidation on chest radiography, ambulance use, hospitalization within 90 days, and comorbidities upon admission. The primary outcome measure was all-cause in-hospital mortality obtained via multivariable logistic regression analysis using four Models. Model 1 involved complete case analysis with overlapping; one hospitalization per patient was counted as one. Model 2 involved a complete case analysis without overlapping; only the first hospitalization per patient was counted. Model 3 involved multilevel analysis clustered by hospital codes. Model 4 was created after multiple imputation for lacking adjusted factors.
A total of 907 hospitals and 7,726 patients were identified. Hemodialysis was significantly associated with lower in-hospital mortality in all models (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.54-0.87 in Model 1; OR = 0.71, 95% CI: 0.55-0.91 in Model 2; OR = 0.67, 95% CI: 0.52-0.86 in Model 3; and OR = 0.68, 95% CI: 0.54-0.87 in Model 4).
Previously-initiated hemodialysis may be an independent prognostic factor for in-hospital mortality in pneumonia patients with end-stage renal disease. This should be borne in mind when considering the time of initiation of dialysis.
一些临床医生会让处于 5 期慢性肾脏病（CKD）的患者暂时不接受血液透析。本研究旨在探究对于因肺炎住院的 5 期 CKD 患者，是否先前开始的血液透析可成为院内死亡率的一个预后因素。
本研究通过多机构诊断程序组合数据库，获取了 2012 年 4 月 1 日至 2016 年 3 月 31 日期间的数据。纳入的患者入院时的主要诊断为肺炎，同时伴有终末期肾病（ESRD）或 5 期 CKD 的记录，或入院时的其他诊断中包含 ESRD 或 5 期 CKD，且年龄≥18 岁。调整的因素包括年龄、性别、体重指数、巴氏指数、定向障碍、动脉血氧饱和度、收缩压、C 反应蛋白水平或胸部 X 线片的实变程度、是否使用救护车、入院 90 天内的住院次数，以及入院时的合并症。主要结局指标为通过多变量逻辑回归分析获得的全因院内死亡率，共使用了 4 个模型。模型 1 为重叠的完全病例分析，每位患者的一次住院算作一次；模型 2 为不重叠的完全病例分析，每位患者仅计算第一次住院；模型 3 为按医院代码聚类的多水平分析；模型 4 为在缺失调整因素的情况下进行多次插补后创建的模型。
共纳入 907 家医院和 7726 例患者。在所有模型中，血液透析与较低的院内死亡率显著相关（模型 1 中的比值比 [OR] = 0.68，95%置信区间 [CI]：0.54-0.87；模型 2 中的 OR = 0.71，95% CI：0.55-0.91；模型 3 中的 OR = 0.67，95% CI：0.52-0.86；模型 4 中的 OR = 0.68，95% CI：0.54-0.87）。
对于患有终末期肾病的肺炎患者，先前开始的血液透析可能是院内死亡率的一个独立预后因素。在考虑开始透析的时间时，应考虑到这一点。
