Kim Hyung Woo, Jhee Jong Hyun, Joo Young Su, Yang Ki Hwa, Jung Jin Ju, Shin Ji Hyeon, Han Seung Hyeok, Yoo Tae-Hyun, Kang Shin-Wook, Park Jung Tak
Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.
Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
J Nephrol. 2022 Dec;35(9):2351-2361. doi: 10.1007/s40620-022-01356-3. Epub 2022 Jun 6.
Improvement in life expectancy has increased the number of very elderly patients undergoing hemodialysis. However, it is not clear which quality measures for hemodialysis should be employed in this population. Therefore, in this paper we investigated the association between major adverse cardiovascular and cerebrovascular events (MACCE) indicators of hemodialysis quality in very elderly patients. PATIENTS AND METHODS: Data regarding a total of 29,692 patients undergoing maintenance hemodialysis (median age 61 years, 41.5% females) who participated in a national hemodialysis quality assessment program were analyzed. They were divided into < 80 years and ≥ 80 years age groups. The primary and secondary outcomes were MACCE and all-cause mortality, respectively. The association between the outcomes and some of the most widely used standard hemodialysis quality-of-care indicators, including spKt/V, hemoglobin, serum calcium, serum phosphate, and albumin levels, was evaluated. To explore the association between Cox proportional hazard models were constructed. Model 1 was adjusted for age and sex. Model 2 included additional demographic characteristics, such as Charlson Comorbidity Index (excluding diabetes), diabetes, cause of ESKD, dialysis vintage, BMI, and pre-dialysis systolic blood pressure. Model 3 was further adjusted for the main medications. To evaluate the relationship between MACCE risk and quality assessment indicators as a continuous variable, cubic spline analyses were conducted.
During a median follow-up of 3.7 years, MACCE occurred at a higher rate in the ≥ 80-years group than in the < 80-years group (282.0 vs. 110.1 events/1000 person-years). Multivariate Cox regression analysis revealed that spKt/V, serum calcium and phosphate, and hemoglobin levels were associated with MACCE and all-cause mortality risk in patients aged < 80 years. However, these indicators showed no significant relationship with MACCE and all-cause mortality in patients aged ≥ 80 years. Low serum albumin levels were significantly associated with increased MACCE and all-cause mortality risks, regardless of age.
In conclusion, hemodialysis quality-of-care indicators including spKt/V, serum calcium and phosphate levels, and hemoglobin were not related to MACCE or all-cause mortality in very elderly hemodialysis patients. However, lower serum albumin levels were associated with poor outcomes, regardless of patient age. Assuring nutritional status rather than improving hemodialysis management adequacy may be more beneficial for improving outcomes in very elderly hemodialysis patients. Further prospective evaluations are needed to confirm these findings.
预期寿命的提高使得接受血液透析的高龄患者数量增加。然而，目前尚不清楚该人群应采用哪些血液透析质量指标。因此，在本文中，我们研究了高龄患者血液透析质量的主要不良心血管和脑血管事件（MACCE）指标之间的关联。
分析了参与全国血液透析质量评估项目的总共29692例接受维持性血液透析的患者（中位年龄61岁，女性占41.5%）的数据。他们被分为年龄＜80岁和≥80岁两个年龄组。主要结局和次要结局分别为MACCE和全因死亡率。评估了结局与一些最广泛使用的标准血液透析护理质量指标之间的关联，这些指标包括标准化Kt/V、血红蛋白、血清钙、血清磷和白蛋白水平。为了探究关联，构建了Cox比例风险模型。模型1根据年龄和性别进行了调整。模型2纳入了其他人口统计学特征，如Charlson合并症指数（不包括糖尿病）、糖尿病、终末期肾病病因、透析龄、体重指数和透析前收缩压。模型3进一步根据主要用药情况进行了调整。为了评估MACCE风险与作为连续变量的质量评估指标之间的关系，进行了三次样条分析。
在中位随访3.7年期间，≥80岁组MACCE的发生率高于＜80岁组（282.0 vs. 110.1事件/1000人年）。多变量Cox回归分析显示，标准化Kt/V、血清钙和磷以及血红蛋白水平与＜80岁患者的MACCE和全因死亡风险相关。然而，这些指标在≥80岁患者中与MACCE和全因死亡率无显著关系。无论年龄如何，低血清白蛋白水平均与MACCE和全因死亡风险增加显著相关。
总之，包括标准化Kt/V、血清钙和磷水平以及血红蛋白在内的血液透析护理质量指标与高龄血液透析患者的MACCE或全因死亡率无关。然而，无论患者年龄如何，较低的血清白蛋白水平均与不良结局相关。确保营养状况而非提高血液透析管理的充分性可能对改善高龄血液透析患者的结局更有益。需要进一步的前瞻性评估来证实这些发现。
