School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK.
Department of Renal Medicine, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK.
Nephrol Dial Transplant. 2023 Feb 13;38(2):435-446. doi: 10.1093/ndt/gfac274.
Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard 4 h thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness.
We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27 February 2022. Eligible studies compared incremental haemodialysis (sessions either fewer than three times weekly or of duration <3.5 h) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4.
A total of 644 records were identified. Twenty-six met the inclusion criteria, including 22 cohort studies and two randomized controlled trials (RCTs). Sample size ranged from 48 to 50 596 participants (total 101 476). We found no mortality differences (hazard ratio = 0.99; 95% CI 0.80-1.24). Cohort studies suggested similar hospitalization rates though the two small RCTs suggested less hospitalization after incremental initiation (relative risk = 0.31; 95% CI 0.18-0.54). Data on other treatment-emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments.
Incremental initiation of haemodialysis does not confer greater risk of mortality compared with standard treatment. Hospitalization may be reduced and costs are lower.
与标准的每周三次、每次 4 小时的方案相比，递增式血液透析起始方案的治疗时间更短、频次更低。随着残余肾功能（RKF）下降，透析剂量逐渐增加。本系统评价评估了递增式血液透析起始方案的安全性、疗效和成本效益。
我们检索了 MEDLINE、EMBASE、CINAHL 和 Cochrane 图书馆数据库，检索时间截至 2022 年 2 月 27 日。纳入的研究将递增式血液透析（每周治疗次数少于 3 次或每次治疗时间少于 3.5 小时）与标准治疗进行了比较。主要结局为死亡率。次要结局包括治疗中出现的不良事件、RKF 丧失、生活质量和成本效益。研究方案进行了前瞻性注册。使用纽卡斯尔-渥太华量表和修订后的 Cochrane 偏倚风险工具对偏倚风险进行评估。采用 Review Manager 软件进行 Meta 分析，版本 5.4。
共确定了 644 条记录。26 项研究符合纳入标准，包括 22 项队列研究和 2 项随机对照试验（RCT）。样本量范围为 48 至 50596 名参与者（总计 101476 名）。我们没有发现死亡率差异（风险比=0.99；95%CI 0.80-1.24）。队列研究表明住院率相似，但是两项小型 RCT 表明递增起始治疗后住院率较低（相对风险=0.31；95%CI 0.18-0.54）。关于其他治疗中出现的不良事件和生活质量的数据有限。观察性研究表明，递增式血液透析可减少 RKF 的丧失，但 RCT 数据并未证实这一点。四项研究报告了递增治疗的成本降低。
与标准治疗相比，递增式血液透析起始方案并不会增加死亡率风险。可能会降低住院率，同时降低成本。
