Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, Taiwan.
BMC Nephrol. 2020 Aug 6;21(1):331. doi: 10.1186/s12882-020-01988-2.
Hemodialysis patients have a high risk of mortality. The most common causes of death are cardiovascular disease and infection. The potential hazard or benefit associated with vitamin D use and cardiovascular or infection outcome is poorly characterized.
We conducted a retrospective observational cohort study by recruiting 52,757 patients older than 20 years from Taiwan National Health Insurance Research Database (NHIRD) who initiated maintenance hemodialysis between 2001 and 2009. Patients who were prescribed activated vitamin D before the 360th day from hemodialysis initiation were defined as vitamin D users. The primary outcome of interest includes occurrence of acute myocardial infarction (AMI), ischemic stroke, lower limb amputation, and hospitalization for infection, respectively, while death events are treated as competing events. We conducted competing risk analysis using subdistribution hazard regression model to estimate subdistribution hazard ratios (SHRs) in relation to various outcomes.
During the median follow-up of 1019 days, the vitamin D users had a lower crude mortality rate, lower incidences of AMI, ischemic stroke, amputation, and hospitalization for infection compared with non-users. Taking into consideration competing events of death, vitamin D users were associated with a lower hazard of lower limb amputation (SHR 0.84 [95% CI, 0.74-0.96]) and hospitalization for infection (SHR 0.90 [95% CI, 0.87-0.94]), but not AMI or ischemic stroke, after adjustment for potential confounders. Subgroup analyses and dose response evaluation both showed a consistent association of activated vitamin D treatment with decreased risk of amputation and infection.
The findings suggest that therapeutic activated vitamin D use in hemodialysis patients may be beneficial for decreasing infection events and amputation, of which the latter is a complication of peripheral vascular disease, rather than reducing major atherosclerotic cardiovascular events such as AMI or ischemic stroke.
血液透析患者的死亡率较高。导致死亡的最常见原因是心血管疾病和感染。维生素 D 的使用与心血管或感染结果相关的潜在危害或益处尚未得到充分描述。
我们通过从台湾国家健康保险研究数据库（NHIRD）中招募了 52757 名 20 岁以上在 2001 年至 2009 年期间开始维持性血液透析的患者，进行了一项回顾性观察性队列研究。在血液透析开始后的 360 天内被处方活性维生素 D 的患者被定义为维生素 D 使用者。主要研究结果包括急性心肌梗死（AMI）、缺血性中风、下肢截肢和因感染住院的发生率，而死亡事件被视为竞争事件。我们使用亚分布风险回归模型进行竞争风险分析，以估计与各种结果相关的亚分布风险比（SHR）。
在中位随访 1019 天期间，与非使用者相比，维生素 D 使用者的死亡率较低，AMI、缺血性中风、截肢和感染住院的发生率较低。考虑到死亡的竞争事件，在调整了潜在混杂因素后，维生素 D 使用者的下肢截肢风险（SHR 0.84[95%CI，0.74-0.96]）和感染住院风险（SHR 0.90[95%CI，0.87-0.94]）较低，但 AMI 或缺血性中风风险没有降低。亚组分析和剂量反应评估均表明，活性维生素 D 治疗与降低截肢和感染风险之间存在一致的关联。
研究结果表明，血液透析患者的治疗性活性维生素 D 使用可能有益于减少感染和截肢事件，其中后者是外周血管疾病的并发症，而不是减少 AMI 或缺血性中风等主要动脉粥样硬化性心血管事件。
