Belcher John, Coyle David, Lindley Elizabeth J, Keane David, Caskey Fergus J, Dasgupta Indranil, Davenport Andrew, Farrington Ken, Mitra Sandip, Ormandy Paula, Wilkie Martin, Macdonald Jamie, Solis-Trapala Ivonne, Sim Julius, Davies Simon J
School of Medicine, Keele University, Keele, United Kingdom.
NIHR Devices for Dignity, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
Kidney360. 2025 Jan 1;6(1):112-120. doi: 10.34067/KID.0000000596. Epub 2024 Oct 10.
Residual kidney function during the first 2 years of hemodialysis treatment is associated with a long-term (>4 years) survival advantage. Incorporating bioimpedance measurements to inform the setting of the postdialysis target weight does not affect patient survival.
Preservation of residual kidney function (RKF) in dialysis patients has been associated with improved survival. RKF in the BISTRO trial was relatively well preserved, and in this study, we describe its association with survival during the trial and extended follow-up.
RKF, measured as the average urea and creatinine clearance (GFR) or 24-hour urine volume, was assessed at baseline; 1, 2, and 3 months; and every three months for up to 2 years in incident hemodialysis patients. Time to event survival data or competing events (transplantation, modality change) was obtained for 50 months after enrollment data linkage with the UK Renal Registry. Cox proportional hazards regression survival models, including those incorporating change in GFR from baseline as a time-varying variable and joint regression models for longitudinal and survival data (longitudinal models for GFR or urine volume), were used to explore the relationship of RKF preservation with survival. Analyses were adjusted for age, sex, comorbidity, and ethnicity.
A total of 2919 measures of RKF were made in 387 patients from 32 UK dialysis units. Higher age and comorbidity score were associated with increased mortality in all models. Baseline GFR reduced the risk of death (hazard ratio [HR], 0.918; 95% confidence interval [CI], 0.844 to 0.999) per ml/min per 1.73 m. A greater fall in GFR and urine volume from baseline was associated with a nonsignificant increased risk of death, as visualized on spline plots. In the joint survival models, higher GFR (adjusted HR, 0.88; 95% CI, 0.80 to 0.97) or urine volume (adjusted HR, 0.75, 95% CI, 0.57 to 0.95/L) at any time point was associated with better survival.
Lower RKF during the first 2 years of hemodialysis is associated with an increased death risk for up to 50 months after dialysis initiation. This adds to a growing body of evidence that interventions to preserve RKF should be developed and tested in clinical trials.
血液透析治疗的头两年残余肾功能与长期（>4年）生存优势相关。采用生物电阻抗测量来设定透析后目标体重并不影响患者生存。
透析患者残余肾功能（RKF）的保留与生存率提高相关。BISTRO试验中的RKF得到了相对较好的保留，在本研究中，我们描述了其在试验期间及延长随访期与生存的关联。
以平均尿素和肌酐清除率（GFR）或24小时尿量来衡量的RKF在基线、第1、2和3个月以及长达2年的时间里，每三个月对新进入血液透析的患者进行评估。入组后50个月获取事件发生时间生存数据或竞争事件（移植、透析方式改变）的数据，并与英国肾脏登记处进行数据关联。使用Cox比例风险回归生存模型，包括那些将GFR相对于基线的变化作为时间变化变量的模型，以及纵向和生存数据的联合回归模型（GFR或尿量的纵向模型），来探讨RKF保留与生存的关系。分析对年龄、性别、合并症和种族进行了调整。
来自英国32个透析单位的387名患者共进行了2919次RKF测量。在所有模型中，年龄较大和合并症评分较高与死亡率增加相关。基线GFR每毫升/分钟每1.73平方米降低死亡风险（风险比[HR]，0.918；95%置信区间[CI]，0.844至0.999）。如样条图所示，GFR和尿量相对于基线的更大下降与死亡风险非显著增加相关。在联合生存模型中，任何时间点较高的GFR（调整后HR，0.88；95%CI，0.80至0.97）或尿量（调整后HR，0.75，95%CI，0.57至0.95/L）与更好的生存相关。
血液透析头两年较低的RKF与透析开始后长达50个月的死亡风险增加相关。这进一步证明了应在临床试验中开发和测试保留RKF的干预措施。
