Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.
Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Department of Pediatric Nephrology, Shengjing Hospital of China Medical University, Shenyang, China.
Am J Kidney Dis. 2019 Jun;73(6):797-805. doi: 10.1053/j.ajkd.2018.12.038. Epub 2019 Mar 2.
RATIONALE & OBJECTIVE: The association of estimated glomerular filtration rate (eGFR) at dialysis therapy initiation with mortality among adult dialysis patients has been greatly debated, with some studies showing no benefit from early dialysis therapy initiation. However, this association has not been well investigated in pediatric dialysis patients. The objective of this study was to evaluate the mortality risk associated with eGFR at dialysis therapy initiation in children and adolescents with kidney failure.
Retrospective cohort study.
SETTING & PARTICIPANTS: 9,963 incident dialysis patients aged 1 to 17 years in the US Renal Data System registry (1995-2016).
eGFRs at dialysis therapy initiation calculated using the pediatric-specific bedside Schwartz equation (<5, 5-<7, 7-<9, 9-<12, and ≥12mL/min/1.73m).
Time to all-cause death.
Cox proportional hazards regression adjusted for case-mix variables, height, body mass index, hemoglobin level, and serum albumin level.
Median eGFR was 7.8 (IQR, 5.6-10.5) mL/min/1.73m and median age was 13 (IQR, 9-16) years. 696 deaths were observed during the median follow-up of 1.4 (IQR, 0.7-2.7) years, and overall crude mortality rate was 31 per 1,000 patient-years. There appeared to be a trend toward higher mortality risk across higher eGFRs at dialysis therapy initiation. Compared with eGFRs of 7 to <9mL/min/1.73m, eGFRs <5 and ≥12mL/min/1.73m were associated with lower and higher mortality, with adjusted HRs of 0.57 (95% CI, 0.43-0.74) and 1.31 (95% CI, 1.05-1.65), respectively. In age-stratified analysis, there were consistent relationships among patients 6 years and older while the eGFR-mortality association was attenuated among patients younger than 6 years (P = 0.002).
Possible errors in eGFRs due to methods for serum creatinine measurement. Unmeasured confounders related to eGFR at dialysis therapy initiation.
Higher eGFR at dialysis therapy initiation was associated with higher mortality risk. Further studies of eGFR at initiation are needed in pediatric dialysis patients, especially among those younger than 6 years.
在开始透析治疗时估算肾小球滤过率（eGFR）与成年透析患者死亡率之间的关联存在很大争议，一些研究表明早期透析治疗并无获益。然而，这一关联在儿科透析患者中尚未得到很好的研究。本研究旨在评估儿童和青少年肾衰竭患者开始透析治疗时 eGFR 与死亡率之间的相关性。
回顾性队列研究。
美国肾脏病数据系统登记处 1995-2016 年间年龄为 1 至 17 岁的 9963 例新透析患者。
使用儿童专用床边 Schwartz 方程计算的开始透析治疗时的 eGFR（<5、5-<7、7-<9、9-<12 和≥12 mL/min/1.73m）。
全因死亡时间。
使用 Cox 比例风险回归模型调整病例组合变量、身高、体重指数、血红蛋白水平和血清白蛋白水平。
中位 eGFR 为 7.8（IQR，5.6-10.5）mL/min/1.73m，中位年龄为 13（IQR，9-16）岁。中位随访 1.4（IQR，0.7-2.7）年期间共观察到 696 例死亡，总粗死亡率为 31 例/1000 患者年。在开始透析治疗时 eGFR 越高，死亡率风险似乎越高。与 7-<9mL/min/1.73m 相比，eGFR<5 和≥12mL/min/1.73m 与较低和较高的死亡率相关，调整后的 HR 分别为 0.57（95%CI，0.43-0.74）和 1.31（95%CI，1.05-1.65）。在年龄分层分析中，6 岁及以上患者之间存在一致的关系，而 6 岁以下患者的 eGFR-死亡率相关性减弱（P=0.002）。
由于血清肌酐测量方法的原因，eGFR 可能存在误差。开始透析治疗时 eGFR 相关的未测量混杂因素。
开始透析治疗时较高的 eGFR 与较高的死亡率风险相关。需要对儿科透析患者进一步研究开始透析治疗时的 eGFR，尤其是 6 岁以下的患者。
