Schachter Michael E, Saunders Marc J, Akbari Ayub, Caryk Julia M, Bugeja Ann, Clark Edward G, Tennankore Karthik K, Martinusen Dan J
Division of Nephrology, Vancouver Island Health Authority, Victoria, BC, Canada.
Master of Biomedical Technology Program, University of Calgary, AB, Canada.
Can J Kidney Health Dis. 2020 Dec 7;7:2054358120975305. doi: 10.1177/2054358120975305. eCollection 2020.
Long-duration (7-8 hours) hemodialysis provides benefits compared with conventional thrice-weekly, 4-hour sessions. Nurse-administered, in-center nocturnal hemodialysis (INHD) may expand the population to whom an intensive dialysis schedule can be offered.
The primary objective of this study was to determine predictors of INHD technique failure, disruptions, and technique survival.
This study used retrospective chart and database review methodology.
This study was conducted at a single Canadian INHD program operating in Victoria, British Columbia, within a tertiary care hospital. Our program serves a catchment population of approximately 450 000 people.
PATIENTS/SAMPLE/PARTICIPANTS: Forty-three consecutive incident INHD patients took part in the INHD program of whom 42 provided informed consent to participate in this study.
We conducted a retrospective observational study including incident INHD patients from 2015 to 2017. The primary outcome was technique failure ≤6 months (TF ≤6). Secondary outcomes included technique survival and reasons for/predictors of INHD discontinuation or temporary disruption. Predictors of each outcome included demographics, comorbidities, and Clinical Frailty Scale (CFS) scoring.
Among 42 patients, mean (SD) age, dialysis vintage, CFS score, and follow-up were 63 (16) years, 46 (55) months, 4 (1), and 11 (9) months, respectively. 52% were aged ≥65 years. TF ≤6 occurred in 12 (29%) patients. One-year technique survival censored for transplants and home dialysis transitions was 60%. Discontinuation related to insomnia (32%), medical status change (27%), and vascular access (23%). In unadjusted Cox survival analysis, 1-point increases in CFS score associated with a higher risk of technique failure (hazard ratio: 2.04, 95% confidence interval [CI]: 1.26-3.31). In an adjusted analysis, higher frailty severity also associated with temporary INHD disruptions (incidence rate ratio: 2.64, 95% CI: 1.55-4.50, comparing CFS of ≥4 to 1-3).
The retrospective, observational design of this study resulted in limited ability to control for confounding factors. In addition, the relatively small number of events observed owing to a small sample size diminished statistical power to inform study conclusions. Use of a single physician to determine the clinical frailty score is another limitation. Finally, the use of a single center for this study limits generalizability to other programs and clinic settings.
INHD is a sustainable modality, even among older patients. Higher frailty associates with INHD technique failure and greater missed treatments. Inclusion of a CFS threshold of ≤4 into INHD inclusion criteria may help to identify individuals most likely to realize the long-term benefits of INHD.
Due to the retrospective and observational design of this study, trial registration was not necessary.
与传统的每周三次、每次4小时的透析疗程相比，长时间（7 - 8小时）血液透析具有诸多益处。由护士操作的中心夜间血液透析（INHD）可能会扩大能够接受强化透析方案的人群范围。
本研究的主要目的是确定INHD技术失败、中断及技术存活的预测因素。
本研究采用回顾性图表和数据库审查方法。
本研究在加拿大不列颠哥伦比亚省维多利亚市一家三级护理医院内的单一INHD项目中进行。我们的项目服务于约45万人口的集水区。
患者/样本/参与者：43例连续的初治INHD患者参加了INHD项目，其中42例提供了参与本研究的知情同意书。
我们进行了一项回顾性观察研究，纳入了2015年至2017年的初治INHD患者。主要结局是技术失败≤6个月（TF≤6）。次要结局包括技术存活以及INHD中断或暂时中断的原因/预测因素。每个结局的预测因素包括人口统计学、合并症和临床衰弱量表（CFS）评分。
42例患者的平均（标准差）年龄为63（16）岁，透析时间为46（55）个月，CFS评分为4（1），随访时间为11（9）个月。52%的患者年龄≥65岁。12例（29%）患者出现TF≤6。因移植和家庭透析转换而进行的一年技术存活审查率为60%。中断与失眠（32%）、医疗状况变化（27%）和血管通路（23%）有关。在未调整的Cox生存分析中，CFS评分每增加1分与技术失败风险较高相关（风险比：2.04，95%置信区间[CI]：1.26 - 3.31）。在调整分析中，较高的衰弱严重程度也与INHD暂时中断相关（发病率比：2.64，95%CI：1.55 - 4.50，比较CFS≥4与1 - 3）。
本研究的回顾性观察设计导致控制混杂因素的能力有限。此外，由于样本量较小，观察到的事件数量相对较少，削弱了为研究结论提供信息的统计效力。使用单一医生确定临床衰弱评分是另一个局限性。最后，但并非最不重要的一点是，本研究使用单一中心限制了其对其他项目和临床环境的可推广性。
INHD是一种可持续的治疗方式，即使在老年患者中也是如此。较高的衰弱程度与INHD技术失败和更多的治疗缺失相关。将CFS阈值≤4纳入INHD纳入标准可能有助于识别最有可能实现INHD长期益处的个体。
由于本研究的回顾性和观察性设计，无需进行试验注册。
