Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA,
Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota, USA,
Am J Nephrol. 2020;51(3):227-236. doi: 10.1159/000505993. Epub 2020 Feb 4.
Associations of demographic factors with elective dialysis withdrawal and setting of death, patterns of illness trajectories preceding death, and how illness trajectories, particularly worsening putative disability, are associated with elective withdrawal are poorly understood.
Using United States Renal Data System data, we performed a case-control analysis of hemodialysis patients who died in 2010-2015. A disability proxy score characterized disability; logistic regression identified characteristics associated with death from withdrawal and with death setting; and group-based trajectory models characterized the trajectory of disability in the months preceding death.
We identified 14,571 (9.2%) patients who withdrew and 144,305 (90.8%) who died of a non-withdrawal cause. Women were more likely than men to withdraw (OR 1.19, 95% CI 1.15-1.24). The most rural patients were more likely to withdraw than the most urban (OR 1.37, 95% CI 1.25-1.50). Medicaid coverage (a marker for impoverishment) was associated with less withdrawal (OR 0.90, 95% CI 0.86-0.94). Disability proxy score was strongly related to withdrawal: the OR for patients in the highest score category was 31.16 (95% CI 28.40-34.20) versus those with a score of 0. Women and whites (vs. blacks) were overrepresented in the worst, versus better, proxy disability score trajectory. In-hospital death and death in the intensive care unit were more common in women and minorities than in men and whites, but less common in the most rural patients.
Important differences separate patients who electively withdraw from those who die of non-withdrawal causes. Worsening disability, in particular, may be a marker for withdrawal.
人口因素与择期透析退出和死亡地点的关联、死亡前疾病轨迹的模式，以及疾病轨迹（尤其是假定残疾恶化）如何与择期退出相关联，这些都知之甚少。
我们使用美国肾脏数据系统的数据，对 2010-2015 年期间死亡的血液透析患者进行了病例对照分析。使用残疾代理评分来描述残疾情况；使用逻辑回归确定与退出相关的死亡和死亡地点的特征；并使用基于群组的轨迹模型来描述死亡前几个月残疾的轨迹。
我们确定了 14571 名（9.2%）退出治疗的患者和 144305 名（90.8%）死于非退出原因的患者。与男性相比，女性更有可能退出治疗（比值比 1.19，95%可信区间 1.15-1.24）。最农村的患者比最城市的患者更有可能退出治疗（比值比 1.37，95%可信区间 1.25-1.50）。医疗补助覆盖（贫困的标志）与退出治疗的可能性降低相关（比值比 0.90，95%可信区间 0.86-0.94）。残疾代理评分与退出治疗密切相关：得分最高类别的患者的比值比为 31.16（95%可信区间 28.40-34.20），而得分 0 的患者的比值比为 1。女性和白人（与黑人相比）在最差的残疾代理评分轨迹中所占比例过高，而在最好的轨迹中所占比例过低。与男性和白人相比，女性和少数民族患者的院内死亡和重症监护病房死亡更为常见，但在最农村的患者中则较少见。
选择退出治疗的患者与非退出治疗原因导致死亡的患者之间存在重要差异。特别是残疾恶化可能是退出治疗的一个标志。
