Public Health Departments, Group Methods in Clinical Research, University Hospital of Strasbourg, Strasbourg, France.
School of Medicine, University of Strasbourg, Strasbourg, France.
J Nephrol. 2022 Apr;35(3):977-988. doi: 10.1007/s40620-021-01188-7. Epub 2021 Nov 24.
Unfavorable conditions at hemodialysis inception reduce the survival rate. However, the relative contribution to outcomes of predialysis follow-up, symptoms, emergency start or central venous catheter (CVC) is unknown.
We analyzed the determinants of survival according to dialysis initiation conditions in the nationwide REIN registry, using two methods based either on clinical classification or data mining. We divided patients into four groups according to dialysis initiation (emergency vs planned, symptoms or not, previous follow-up). "Followed planned starters" began dialysis as outpatients and with an arteriovenous fistula (AVF). "Followed symptomatic non-urgent starters" were patients who started earlier because of any non-urgent symptomatic event. "Followed urgent starters" had seen a nephrologist before inception but started dialysis in an emergency condition. "Unknown urgent starters" were patients without any follow-up and who had a CVC at inception.
"Followed urgent" starters had the lowest 2-year survival rate (66.8%) compared to "followed planned" (77.3%), "followed symptomatic non urgent" (79.2%), and "unknown urgent" (71.7%). Compared to other groups, the risk of mortality was lower in followed symptomatic non urgent (HR 0.86 95% CI 0.75-0.99) and higher in followed urgent starters (HR 1.05 (95% CI 0.94-1.18). In data mining Classification And Regression Tree regrouping in five categories, the lowest 2-year survival (52.3%) was in over 70-year-old starters with a CVC. The survival was 93.2% in under 57-year-old patients without active cancer, 82.5% in 57-70-year-old individuals without cancer, 72.4% in over 70-year-old patients without CVC and 61.4% in under 70-year-old subjects with cancer. The hazard ratio of data mining categories varied between 2.12 (95% CI 1.73-2.60) in 57-70-year-old subjects without cancer and 4.42 (95% CI 3.64-5.37) in over 70-year-old patients with CVC. Therefore, regrouping incident patients into five data mining categories, identified by age, cancer, and CVC use, could discriminate the 2-year survival in patients starting hemodialysis.
Although each classification captured different prognosis information, both analyses showed that starting hemodialysis on a CVC has more dramatic outcomes than emergency start per se.
血液透析开始时的不利条件会降低生存率。然而，关于透析前随访、症状、急诊开始或中心静脉导管（CVC）对结果的相对贡献尚不清楚。
我们使用基于临床分类或数据挖掘的两种方法，根据全国范围内的 REIN 登记处的透析开始条件分析生存的决定因素。我们根据透析开始（急诊与计划、有症状或无症状、是否有前期随访）将患者分为四组。“随访计划开始者”作为门诊患者并使用动静脉瘘（AVF）开始透析。“随访有症状的非紧急开始者”是指因任何非紧急症状而更早开始透析的患者。“随访紧急开始者”在开始前已看过肾病医生，但在紧急情况下开始透析。“未知紧急开始者”是指没有任何随访且在开始时就已使用 CVC 的患者。
与“随访计划开始者”（77.3%）、“随访有症状的非紧急开始者”（79.2%）和“未知紧急开始者”（71.7%）相比，“随访紧急开始者”的 2 年生存率最低（66.8%）。与其他组相比，随访有症状的非紧急开始者的死亡率风险较低（HR 0.86，95%CI 0.75-0.99），而随访紧急开始者的死亡率风险较高（HR 1.05，95%CI 0.94-1.18）。在数据挖掘分类和回归树重新分类为五类中，70 岁以上且使用 CVC 的患者的 2 年生存率最低（52.3%）。70 岁以下无活动性癌症的患者的生存率为 93.2%，57-70 岁无癌症的患者为 82.5%，70 岁以上无 CVC 的患者为 72.4%，70 岁以下有癌症的患者为 61.4%。数据挖掘分类的风险比在 57-70 岁无癌症的患者中为 2.12（95%CI 1.73-2.60），在 70 岁以上使用 CVC 的患者中为 4.42（95%CI 3.64-5.37）。因此，将事件患者重新分类为五类数据挖掘类别，根据年龄、癌症和 CVC 使用情况进行分类，可以区分开始血液透析的患者的 2 年生存率。
尽管每种分类都捕捉到了不同的预后信息，但两种分析都表明，与急诊开始透析相比，使用 CVC 开始血液透析的结果更为严重。
