Murakami Minoru, Fujii Naohiko, Kanda Eiichiro, Kikuchi Kan, Wada Atsushi, Hamano Takayuki, Masakane Ikuto
Department of Nephrology, Saku Central Hospital, Nagano, Japan.
Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.
Am J Nephrol. 2024;55(6):647-656. doi: 10.1159/000541356. Epub 2024 Sep 7.
The optimal time for vascular access (VA) creation remains controversial.
We conducted a cohort study using data from the Japanese Society for Dialysis Therapy Renal Data Registry. Adult patients who started receiving hemodialysis in 2007 and had a permanent VA created were included. The exposure of interest was the timing of VA creation, categorized into three groups: early VA creation (defined as creation at least 4 months before hemodialysis initiation), just prior VA creation (creation between 1 and 3 months before hemodialysis initiation), and late VA creation (creation within 1 month of or after hemodialysis initiation). Cox regression analyses were used to compare 1-year all-cause mortality, with late VA creation as the reference group. Owing to the violations of the proportional hazards assumptions, the follow-up period was divided into "early" (1-4 months follow-up) and "late" (5-12 months follow-up) periods.
Overall, 1,280 (15.4%) of 8,322 patients died. Both early creation and just prior creation were associated with lower all-cause mortality in the early period compared with late creation. In the late period, the hazard ratios (HRs) for all-cause mortality decreased with earlier VA creation (adjusted HRs [95% confidence intervals]: 0.49 [0.35-0.67] for the early creation group and 0.63 [0.51-0.79] for the just prior creation group).
Our study suggests that VA creation at least 1 month before hemodialysis initiation is associated with lower all-cause mortality in the early period, with earlier VA creation resulting in further mortality reduction in the late period.
建立血管通路（VA）的最佳时机仍存在争议。
我们使用日本透析治疗学会肾脏数据登记处的数据进行了一项队列研究。纳入了2007年开始接受血液透析并建立永久性VA的成年患者。感兴趣的暴露因素是VA建立的时间，分为三组：早期VA建立（定义为在血液透析开始前至少4个月建立）、临近VA建立（在血液透析开始前1至3个月建立）和晚期VA建立（在血液透析开始后1个月内或之后建立）。采用Cox回归分析比较1年全因死亡率，以晚期VA建立作为参照组。由于违反了比例风险假设，随访期分为“早期”（随访1至4个月）和“晚期”（随访5至12个月）两个阶段。
总体而言，8322例患者中有1280例（15.4%）死亡。与晚期建立相比，早期建立和临近建立在早期均与较低的全因死亡率相关。在晚期，全因死亡率的风险比（HRs）随着VA建立时间的提前而降低（调整后的HRs[95%置信区间]：早期建立组为0.49[0.35 - 0.67]，临近建立组为0.63[0.51 - 0.79]）。
我们的研究表明，在血液透析开始前至少1个月建立VA与早期较低的全因死亡率相关，VA建立时间越早，晚期死亡率进一步降低。
