Department of Nephrology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, China.
Shandong Institute of Nephrology, No.16766 Jingshi Road, Jinan, 250014, China.
BMC Nephrol. 2023 Jun 7;24(1):162. doi: 10.1186/s12882-023-03184-4.
The exact optimal timing of dialysis for ESKD patients remains unknown. This study systematically reviewed the available evidence with regard to the optimal initiation of maintenance dialysis in ESKD patients.
An electronic search was performed in Embase, PubMed and the Cochrane Library in order to find studies investigating associations between variables reference to "start of dialysis" and outcomes. Quality assessment and bias assessment were performed by the Newcastle-Ottawa scale and the ROBINSI tool. Due to the heterogeneity of studies, a meta-analysis could not be performed.
Thirteen studies were included; four studies included only haemodialysis patients, three peritoneal dialysis, six both; study outcomes included mortality, cardiovascular events, technique failure, quality of life and others. Nine studies mainly focused on the optimal GFR of maintenance dialysis initiation; five studies showed none association between GFR and mortality or other adverse outcomes, two studies showed dialysis initiation at higher GFR levels were with poor prognosis, and 2 studies showed higher GFR levels with better prognosis. Three studies paid attention to comprehensive assessment of uremic signs and/or symptoms for optimal dialysis initiation; uremic burden based on 7 uremic indicators (hemoglobin, serum albumin, blood urea nitrogen, serum creatinine, potassium, phosphorus, and bicarbonate) were not associated with mortality; another equation (combination of sex, age, serum creatinine, blood urea nitrogen, serum albumin, haemoglobin, serum phosphorus, diabetes mellitus, and heart failure) based on fuzzy mathematics to assess the timing of haemodialysis initiation was accuracy to prognose 3-year survival; the third study found that volume overload or hypertension was associated with the highest risk for subsequent mortality. Two studies compared urgent or optimal start in dialysis, a study reported increased survival in optimal start patients, another reported no differences between Urgent-Start-PD and Early-Start-PD regarding 6-month outcomes.
Heterogeneity among the studies was quite high, with differences in sample size, variable and group characteristics; no RCT studies were included, which weakened the strength of evidences.
The criteria for dialysis initiation were varied. Most studies proved that GFR at dialysis initiation was not associated with mortality, timing of dialysis initiation should not be based on GFR, assessments of volume load and patient's tolerance to volume overload are prospective approaches.
终末期肾病患者进行透析的最佳时机仍不清楚。本研究系统地回顾了有关终末期肾病患者维持性透析起始最佳时机的现有证据。
在 Embase、PubMed 和 Cochrane Library 中进行电子检索，以查找研究变量与“开始透析”和结局之间关联的研究。使用纽卡斯尔-渥太华量表和 ROBINS-I 工具进行质量评估和偏倚评估。由于研究存在异质性，因此无法进行荟萃分析。
共纳入 13 项研究；4 项研究仅纳入血液透析患者，3 项纳入腹膜透析患者，6 项同时纳入；研究结局包括死亡率、心血管事件、技术失败、生活质量等。9 项研究主要关注维持性透析开始时的最佳肾小球滤过率；5 项研究表明肾小球滤过率与死亡率或其他不良结局之间无关联，2 项研究表明较高肾小球滤过率水平与预后不良相关，2 项研究表明较高肾小球滤过率水平与预后较好相关。3 项研究关注尿毒症症状和/或体征综合评估以确定最佳透析起始时机；基于 7 项尿毒症指标（血红蛋白、血清白蛋白、血尿素氮、血清肌酐、钾、磷和碳酸氢盐）的尿毒症负担与死亡率无关；另一个基于模糊数学的方程（性别、年龄、血清肌酐、血尿素氮、血清白蛋白、血红蛋白、血清磷、糖尿病和心力衰竭）来评估血液透析起始时机对预测 3 年生存率具有准确性；第 3 项研究发现容量过负荷或高血压与随后的死亡率风险最高相关。2 项研究比较了紧急或最佳起始透析，一项研究报告了最佳起始患者的生存率增加，另一项研究报告紧急起始腹膜透析与早期起始腹膜透析在 6 个月结局方面无差异。
研究之间存在高度异质性，样本量、变量和组特征存在差异；未纳入随机对照试验研究，这削弱了证据的强度。
透析起始的标准各不相同。大多数研究表明，透析起始时的肾小球滤过率与死亡率无关，透析起始时间不应基于肾小球滤过率，评估容量负荷和患者对容量过负荷的耐受能力是前瞻性方法。
