Hladek Melissa D, Zhu Jiafeng, Crews Deidra C, McAdams-DeMarco Mara A, Buta Brian, Varadhan Ravi, Shafi Tariq, Walston Jeremy D, Bandeen-Roche Karen
Johns Hopkins School of Nursing, Baltimore, Maryland, USA.
Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Kidney Int Rep. 2022 Jun 23;7(9):2006-2015. doi: 10.1016/j.ekir.2022.06.009. eCollection 2022 Sep.
Although life-saving, the physiologic stress of hemodialysis initiation contributes to physical impairment in some patients. Mortality risk assessment following hemodialysis initiation is underdeveloped and does not account for change over time. Measures of physical resilience, the ability of a physiologic state to overcome physiologic stressors, may help identify patients at higher mortality risk and inform clinical management.
We created 3 resilience categories (improving, stable, and declining) for trajectories of 4 phenotypes (physical function [PF], mental health [MH], vitality [VT], and general health [GH]) using SF-36 data collected the first year after hemodialysis initiation in the Choices for Healthy Outcomes in Caring for ESKD (CHOICE) study on 394 adults aged more than 55 years. Using mixed effects and Cox proportional hazard modeling, we assessed mortality following the first year on dialysis by resilience categories for each phenotype, adjusting for baseline phenotype and other confounders defined over 4 years average follow-up.
Based on global Wald tests, statistically significant associations of PF ( = 0.03) and VT ( = 0.0004) resilience categories with mortality were found independent of covariates. Declining PF trajectory was associated with higher mortality risk (hazard ratio [HR] = 1.32; 95% confidence interval [CI], 1.05-1.66), whereas improving VT trajectory was associated with lower mortality risk (HR= 0.73; 95% CI, 0.53 to 1.00), each as compared to stable trajectory.
Decreased resilience in PF and VT was independently associated with mortality. Phenotypic trajectories provide added value to baseline markers and patient characteristics when evaluating mortality. Hence, resilience measures hold promise for targeting population health interventions to the highest risk patients.
尽管血液透析起始阶段的生理应激具有挽救生命的作用，但在某些患者中会导致身体功能受损。血液透析起始后的死亡风险评估尚不完善，且未考虑随时间的变化。生理恢复力是指生理状态克服生理应激源的能力，其测量指标可能有助于识别死亡风险较高的患者，并为临床管理提供参考。
我们利用在“终末期肾病患者健康结局选择（CHOICE）研究”中收集的394名年龄超过55岁的成年人血液透析起始后第一年的SF-36数据，为4种表型（身体功能[PF]、心理健康[MH]、活力[VT]和总体健康[GH]）的轨迹创建了3种恢复力类别（改善、稳定和下降）。使用混合效应和Cox比例风险模型，我们按每种表型的恢复力类别评估透析第一年之后的死亡率，并对基线表型和在4年平均随访期间确定的其他混杂因素进行了校正。
基于全局Wald检验，发现PF（P = 0.03）和VT（P = 0.0004）恢复力类别与死亡率之间存在统计学上显著的关联，且独立于协变量。PF轨迹下降与较高的死亡风险相关（风险比[HR]=1.32；95%置信区间[CI]，1.05 - 1.66），而VT轨迹改善与较低的死亡风险相关（HR = 0.73；95% CI，0.53至1.00），与稳定轨迹相比均如此。
PF和VT恢复力下降与死亡率独立相关。在评估死亡率时，表型轨迹为基线标志物和患者特征提供了附加价值。因此，恢复力测量有望针对最高风险患者开展人群健康干预。
