Division of Nephrology, Department of Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
JAMA Netw Open. 2022 Oct 3;5(10):e2237580. doi: 10.1001/jamanetworkopen.2022.37580.
The benefits and disadvantages of different pretransplant dialysis modalities and their posttransplant outcomes remain unclear in contemporary kidney transplant care.
To summarize the available evidence of the association of different pretransplant dialysis modalities, including hemodialysis and peritoneal dialysis (PD), with posttransplant outcomes.
MEDLINE, Embase, PubMed, Cochrane Library, Scopus, CINAHL, and gray literature were searched from inception to March 18, 2022 (updated to April 1, 2022), for relevant studies and with no language restrictions.
Randomized clinical trials and nonrandomized observational (case-control and cohort) studies that investigated the association between pretransplant dialysis modality and posttransplant outcomes regardless of age or donor sources (living or deceased) were abstracted independently by 2 reviewers.
Following Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines, 2 reviewers independently extracted relevant information using a standardized approach. Random-effects meta-analysis was used to estimate pooled adjusted hazard ratio (HR) or odds ratio and 95% CI.
Primary outcomes included all-cause mortality, overall graft failure, death-censored graft failure, and delayed graft function. Secondary outcomes included acute rejection, graft vessel thrombosis, oliguria, de novo heart failure, and new-onset diabetes after transplant.
The study analyzed 26 nonrandomized studies (1 case-control and 25 cohort), including 269 715 patients (mean recipient age range, 14.5-67.0 years; reported proportions of female individuals, 29.4%-66.9%) whose outcomes associated with pretransplant hemodialysis vs pretransplant PD were compared. No significant difference, with very low certainty of evidence, was observed between pretransplant PD and all-cause mortality (13 studies; n = 221 815; HR, 0.92 [95% CI, 0.84-1.01]; P = .08) as well as death-censored graft failure (5 studies; n = 96 439; HR, 0.98 [95% CI, 0.85-1.14]; P = .81). However, pretransplant PD was associated with a lower risk for overall graft failure (10 studies; n = 209 287; HR, 0.96 [95% CI, 0.92-0.99]; P = .02; very low certainty of evidence) and delayed graft function (6 studies; n = 47 118; odds ratio, 0.73 [95% CI, 0.70-0.76]; P < .001; low certainty of evidence). Secondary outcomes were inconclusive due to few studies with available data.
Results of the study suggest that pretransplant PD is a preferred dialysis modality option during the transition to kidney transplant. Future studies are warranted to address shared decision-making between health care professionals, patients, and caregivers as well as patient preferences.
不同的移植前透析方式及其移植后结局在当代肾移植护理中仍然不清楚。
总结不同移植前透析方式（包括血液透析和腹膜透析（PD））与移植后结局相关的现有证据。
从开始到 2022 年 3 月 18 日（更新至 2022 年 4 月 1 日），通过 MEDLINE、Embase、PubMed、Cochrane 图书馆、Scopus、CINAHL 和灰色文献检索了相关研究，无语言限制。
独立地由 2 位评审员摘录了随机临床试验和非随机观察性（病例对照和队列）研究，这些研究无论年龄或供体来源（活体或已故）如何，均调查了移植前透析方式与移植后结局之间的关系。
根据系统评价和荟萃分析的首选报告项目以及观察性研究荟萃分析的报告指南，2 位评审员使用标准化方法独立提取了相关信息。使用随机效应荟萃分析来估计汇总调整后的危险比（HR）或优势比和 95%置信区间。
主要结局包括全因死亡率、整体移植物失败、死亡校正移植物失败和延迟移植物功能。次要结局包括急性排斥反应、移植物血管血栓形成、少尿、新发心力衰竭和移植后新发糖尿病。
研究分析了 26 项非随机研究（1 项病例对照和 25 项队列），包括 269715 名患者（平均受者年龄范围为 14.5-67.0 岁；报告的女性比例为 29.4%-66.9%），比较了移植前血液透析与移植前 PD 与患者结局的关系。在全因死亡率（13 项研究；n=221815；HR，0.92 [95%CI，0.84-1.01]；P=0.08）和死亡校正移植物失败（5 项研究；n=96439；HR，0.98 [95%CI，0.85-1.14]；P=0.81）方面，移植前 PD 与全因死亡率之间无显著差异，证据确定性极低。然而，移植前 PD 与整体移植物失败（10 项研究；n=209287；HR，0.96 [95%CI，0.92-0.99]；P=0.02；证据确定性极低）和延迟移植物功能（6 项研究；n=47118；比值比，0.73 [95%CI，0.70-0.76]；P<0.001；证据确定性低）的风险较低有关。由于可用数据较少，次要结局结论不确定。
研究结果表明，移植前 PD 是移植过渡期首选的透析方式。需要进一步的研究来解决医疗保健专业人员、患者和护理人员之间的共同决策以及患者的偏好。
