Álvarez-García Graciela, Nogueira Pérez Ángel, Prieto Alaguero María Pilar, Pérez Garrote Carmen, Díaz Testillano Aránzazu, Moral Caballero Miguel Ángel, Ruperto Mar, González Blázquez Cristina, Barril Guillermina
Department of Nephrology, Hospital Universitario de la Princesa, Madrid, Spain.
Department of Pharmaceutical and Health Sciences, School of Pharmacy, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain.
Front Nutr. 2023 Feb 16;10:1105573. doi: 10.3389/fnut.2023.1105573. eCollection 2023.
Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality.
This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD.
A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT.
Of the 211 patients with ACKD, 47.4% ( = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% ( = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% ( = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD ( = 119 patients; 56.4%) than in home-based RRT ( = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT ( < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least < 0.05).
Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.
营养和炎症状态是晚期慢性肾脏病（ACKD）发病和死亡风险的重要预测因素。迄今为止，关于 ACKD 4-5 期营养状况对肾替代治疗（RRT）方式选择影响的临床研究数量有限。
本研究旨在探讨合并症与营养及炎症状态之间的关系，以及 ACKD 成人患者 RRT 方式选择的决策。
对 2016 年至 2021 年 211 例 4-5 期 ACKD 患者进行回顾性横断面研究。根据严重程度使用 Charlson 合并症指数（CCI）评估合并症（CCI：≤3 分和>3 分）。通过预后营养指数（PNI）、实验室参数[血清白蛋白、前白蛋白和 C 反应蛋白（s-CRP）]以及人体测量进行临床和营养评估。记录不同 RRT 方式（中心血液透析、家庭血液透析（HD）和腹膜透析（PD））的初始决策以及知情治疗选择（CKD 的保守治疗或透析前活体供体移植）。根据性别、在 ACKD 科室的随访时间（≤6 个月和>6 个月）以及 RRT 的初始决策（中心和家庭 RRT）对样本进行分类。进行单因素和多因素回归分析以评估家庭 RRT 的独立预测因素。
211 例 ACKD 患者中，47.4%（n = 100）为 5 期 CKD，主要为老年男性（65.4%）。糖尿病是 CKD 的主要病因（22.7%），高血压作为心血管危险因素的比例为 96.6%。男性的 CCI 评分显著更高，CCI 评分>3 分的严重合并症为 99.1%。在 ACKD 科室的平均随访时间为 9.6±12.8 个月。随访时间>6 个月的患者 CCI 显著更高；与随访<6 个月的患者相比，其估算肾小球滤过率（eGFR）、血清白蛋白、前白蛋白、转铁蛋白和血红蛋白的平均值更高，s-CRP 更低（均 P<0.05）。平均 PNI 评分为 38.9±5.5 分，36.5% 的患者 PNI≤39 分。71.1%（n = 150）的患者血清白蛋白水平>3.8 g/dl，82.9%（n = 175）的患者 s-CRP≤1 mg/dl。蛋白质能量消耗（PEW）患病率为 15.2%。RRT 方式的初始选择中，中心 HD（n = 119 例患者；56.4%）高于家庭 RRT（n = 81 例；40.5%）。选择家庭 RRT 的患者 CCI 评分显著更低，血清白蛋白、前白蛋白、转铁蛋白、血红蛋白和 eGFR 的平均值更高，s-CRP 更低，与选择中心 RRT 的患者相比差异有统计学意义（P<0.001）。逻辑回归显示，血清白蛋白（比值比：0.147）和在 ACKD 科室的随访时间>6 个月（比值比：0.440）与选择家庭 RRT 方式的决策可能性显著相关（均 P<0.05）。
在多学科 ACKD 科室对社会人口学因素、合并症以及营养和炎症状态进行定期监测和随访，对非透析 ACKD 患者 RRT 方式的选择决策和预后有显著影响。
