1995 年至 2015 年开始透析的儿童和青年人群中心血管死亡率趋势。

Trends in Cardiovascular Mortality Among a Cohort of Children and Young Adults Starting Dialysis in 1995 to 2015.

机构信息

Division of Nephrology, Department of Medicine, University of California, San Francisco.

Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco.

出版信息

JAMA Netw Open. 2020 Sep 1;3(9):e2016197. doi: 10.1001/jamanetworkopen.2020.16197.

DOI:10.1001/jamanetworkopen.2020.16197

PMID:32902652

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7489869/

Abstract

IMPORTANCE

Survival of patients receiving dialysis has improved during the last 2 decades. However, few studies have examined temporal trends in the attributed causes of death (especially cardiovascular-related) in young populations.

OBJECTIVE

To determine temporal trends and risk of cause-specific mortality (ie, cardiovascular and infectious) for children and young adults receiving dialysis.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined the records of children and young adults (aged <30 years) starting dialysis between 1995 and 2015 according to the United States Renal Data System database. Analyses were performed between June 2019 and June 2020. Fine-Gray models were used to examine trends in risk of different cardiovascular-related deaths. Models were adjusted for age, sex, race, neighborhood income, cause of end-stage kidney disease, insurance type, and comorbidities. Analyses were performed separately for children (ie, age <18 years) and young adults (between ages 18 and 30 years). Follow-up was censored at death or administratively, and transplantation was treated as a competing event.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Cardiovascular cause-specific mortality.

RESULTS

A total of 80 189 individuals (median [interquartile range] age, 24 [19-28] years; 36 259 [45.2%] female, 29 508 [36.8%] Black, and 15 516 [19.3%] Hispanic white) started dialysis and 16 179 experienced death during a median (interquartile range) of 14.3 (14.0-14.7) years of follow-up. Overall, 40.2% of deaths were from cardiovascular-related causes (6505 of 16 179 patients). In adjusted analysis, risk of cardiovascular-related death was stable initially but became statistically significantly lower after 2006 (vs 1995) in those starting dialysis as either children (subhazard ratio [SHR], 0.74; 95% CI, 0.55-1.00) or adults (SHR, 0.90; 95% CI, 0.83-0.98). Risk of sudden cardiac death improved steadily for all age groups, but to a greater degree in children (SHR, 0.31; 95% CI, 0.20-0.47) vs young adults (SHR, 0.64; 95% CI, 0.56-0.73) comparing 2015 vs 1995. Risk of stroke became statistically significantly lower around 2010 (vs 1995) for children (SHR, 0.40; 95% CI, 0.18-0.88) and young adults (SHR, 0.76; 95% CI, 0.59-0.99).

CONCLUSIONS AND RELEVANCE

In this study, the risk of cardiovascular-related death declined for children and young adults starting dialysis during the last 2 decades, but trends differed depending on age at dialysis initiation and the specific cause of death. Additional studies are needed to improve risk of cardiovascular disease in young populations.

摘要

重要提示

在过去的二十年中，接受透析治疗的患者的生存率得到了提高。然而，很少有研究调查年轻人群中归因于死亡的原因（尤其是心血管相关原因）的时间趋势。

目的

确定接受透析的儿童和青年患者的特定原因死亡率（即心血管和传染性）的时间趋势和风险。

设计、设置和参与者：本回顾性队列研究根据美国肾脏数据系统数据库，对 1995 年至 2015 年期间开始透析的儿童和青年（年龄<30 岁）的记录进行了研究。分析于 2019 年 6 月至 2020 年 6 月之间进行。精细灰色模型用于检查不同心血管相关死亡风险的趋势。模型根据年龄、性别、种族、社区收入、终末期肾病的原因、保险类型和合并症进行了调整。分别对儿童（即年龄<18 岁）和青年（年龄在 18 至 30 岁之间）进行了分析。随访截止于死亡或行政，移植被视为竞争事件。

暴露因素

日历年份。

主要结果和测量指标

心血管原因的特定死亡率。

结果

共有 80189 人（中位数[四分位间距]年龄，24 [19-28] 岁；36259 名[45.2%]女性，29508 名[36.8%]黑人，15516 名[19.3%]西班牙裔白人）开始透析，中位数（四分位间距）随访 14.3（14.0-14.7）年期间，有 16179 人经历了死亡。总体而言，40.2%的死亡是心血管相关原因（16179 名患者中的 6505 人）。在调整分析中，心血管相关死亡的风险最初是稳定的，但在 2006 年（与 1995 年相比）后，无论是儿童（亚危险比[SHR]，0.74；95%CI，0.55-1.00）还是成人（SHR，0.90；95%CI，0.83-0.98）开始透析的患者中，该风险的统计学意义显著降低。所有年龄段的心脏性猝死风险均稳步改善，但儿童的改善程度更大（SHR，0.31；95%CI，0.20-0.47），而青年（SHR，0.64；95%CI，0.56-0.73）相比，2015 年与 1995 年相比。儿童（SHR，0.40；95%CI，0.18-0.88）和青年（SHR，0.76；95%CI，0.59-0.99）的中风风险在 2010 年左右统计学意义显著降低（与 1995 年相比）。