Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA.
Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA.
Am J Nephrol. 2022;53(2-3):157-168. doi: 10.1159/000521508. Epub 2022 Feb 28.
Chronic kidney disease-mineral and bone disorders (CKD-MBD) are prevalent in patients undergoing maintenance dialysis. Yet, there are limited and mixed evidence on the effects of different dialysis modalities involving longer treatment times or higher frequencies on CKD-MBD markers.
This cohort study used data from 132,523 incident dialysis patients treated with any of the following modalities: conventional thrice-weekly in-center hemodialysis, nocturnal in-center hemodialysis (NICHD), home hemodialysis (HHD), or peritoneal dialysis (PD) from 2007 to 2011. We used marginal structural models fitted with inverse probability weights to adjust for fixed and time-varying confounding and informative censoring. We estimated the average effects of treatments with different dialysis modalities on time-varying serum concentrations of CKD-MBD markers: albumin-corrected calcium, phosphate, parathyroid hormone (PTH), and alkaline phosphatase (ALP) using pooled linear regression.
Most of the cohort were exclusively treated with conventional in-center hemodialysis, while few were ever treated with NICHD or HHD. At the baseline, PD patients had the lowest mean and median values of PTH, while NICHD patients had the highest median values. During follow-up, compared to hemodialysis patients, patients treated with NICHD had lower mean serum PTH (19.8 pg/mL [95% confidence interval: 2.8, 36.8] lower), whereas PD and HHD patients had higher mean PTH (39.7 pg/mL [31.6, 47.8] and 51.2 pg/mL [33.0, 69.3] higher, respectively). Compared to hemodialysis patients, phosphate levels were lower for patients treated with NICHD (0.44 mg/dL [0.37, 0.52] lower), PD (0.15 mg/dL [0.12, 0.19] lower), or HHD (0.33 mg/dL [0.27, 0.40] lower). There were no clinically meaningful associations between dialysis modalities and concentrations of calcium or ALP.
In incident dialysis patients, compared to treatment with conventional in-center hemodialysis, treatments with other dialysis modalities with longer treatment times or higher frequency were associated with different patterns of serum phosphate and PTH. Given the recent growth in the use of dialysis modalities other than hemodialysis, the associations between the treatment and the CKD-MBD markers warrant additional study.
慢性肾脏病-矿物质和骨异常（CKD-MBD）在接受维持性透析的患者中较为普遍。然而，关于不同透析方式（包括治疗时间更长或频率更高的透析方式）对 CKD-MBD 标志物影响的证据有限且存在差异。
本队列研究使用了 2007 年至 2011 年期间接受以下任何一种透析方式治疗的 132523 例新透析患者的数据：常规每周三次中心血液透析、夜间中心血液透析（NICHD）、家庭血液透析（HHD）或腹膜透析（PD）。我们使用逆概率加权的边缘结构模型来调整固定和时变混杂因素以及信息性删失的影响。我们使用 pooled 线性回归估计不同透析方式治疗对 CKD-MBD 标志物（白蛋白校正钙、磷、甲状旁腺激素（PTH）和碱性磷酸酶（ALP））的时变血清浓度的平均影响。
队列中的大多数患者仅接受常规中心血液透析治疗，而少数患者曾接受 NICHD 或 HHD 治疗。在基线时，PD 患者的 PTH 均值和中位数最低，而 NICHD 患者的 PTH 中位数最高。在随访期间，与血液透析患者相比，接受 NICHD 治疗的患者的平均血清 PTH 水平较低（低 19.8pg/ml[95%置信区间：2.8, 36.8]），而 PD 和 HHD 患者的 PTH 水平较高（高 39.7pg/ml[31.6, 47.8]和 51.2pg/ml[33.0, 69.3]）。与血液透析患者相比，接受 NICHD 治疗的患者的磷酸盐水平较低（低 0.44mg/dl[0.37, 0.52]），PD（低 0.15mg/dl[0.12, 0.19]）或 HHD（低 0.33mg/dl[0.27, 0.40]）。透析方式与钙或 ALP 浓度之间没有明显的临床关联。
在新透析患者中，与常规中心血液透析相比，治疗时间更长或频率更高的其他透析方式与不同的血清磷酸盐和 PTH 模式有关。鉴于目前除血液透析以外的透析方式的应用不断增加，治疗与 CKD-MBD 标志物之间的关联值得进一步研究。
