Loureiro Harrison Luis, Fu Edouard L, Thomson Peter C, Traynor Jamie P, Mark Patrick B, Stoumpos Sokratis
Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.
Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
Clin Kidney J. 2024 Nov 14;17(12):sfae345. doi: 10.1093/ckj/sfae345. eCollection 2024 Dec.
Prior nonrandomized studies have suggested nephroprotective effects of arteriovenous fistula (AVF) formation, but these are plausibly susceptible to immortal time and selection biases.
We studied patients attending nephrology clinics in the West of Scotland during 2010-22 with an estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m and no prior AVF. Using target trial emulation and a sequential trial design, we simulated a hypothetical trial that would randomize patients to either undergo AVF formation immediately or not to undergo AVF formation. The primary outcome was the difference in eGFR slope for the first 6 months of follow-up, estimated using a mixed-effects model. The secondary outcomes were 5-year absolute risks of dialysis and death, estimated using the Aalen-Johansen and Kaplan-Meier estimators respectively.
A total of 1364 unique patients (mean age 51.1 years, 55.7% male) contributed 3125 person-trials, with 561 in the AVF and 2564 in the no AVF group. Mean eGFR was 12.6 mL/min/1.73 m and the median number of eGFR measurements per person-trial was 7 (interquartile range 4-12). Slope of eGFR decline did not differ significantly between the AVF and no AVF groups (between-group difference -0.67 mL/min/1.73 m/year, 95% CI -1.43, 0.10). The 5-year absolute risk of dialysis was 87% (95% CI 84, 91) in the AVF group and 75% (95% CI 73, 77) in the no AVF group, and the 5-year survival probability was 77% (95% CI 70, 83) in the AVF group and 67% (95% CI 64, 69) in the no AVF group.
In this study of patients with advanced chronic kidney disease, there was no evidence of a nephroprotective effect of AVF formation.
先前的非随机研究表明动静脉内瘘（AVF）形成具有肾脏保护作用，但这些研究可能易受不朽时间偏倚和选择偏倚的影响。
我们研究了2010年至2022年期间在苏格兰西部肾病诊所就诊的估计肾小球滤过率（eGFR）≤15 mL/min/1.73 m²且既往未行AVF的患者。采用目标试验模拟和序贯试验设计，我们模拟了一项假设试验，该试验将患者随机分为立即进行AVF形成组或不进行AVF形成组。主要结局是随访前6个月eGFR斜率的差异，采用混合效应模型进行估计。次要结局是透析和死亡的5年绝对风险，分别采用Aalen-Johansen估计器和Kaplan-Meier估计器进行估计。
共有1364例独特患者（平均年龄51.1岁，55.7%为男性）参与了3125人次试验，其中AVF组561人次，非AVF组2564人次。平均eGFR为12.6 mL/min/1.73 m²，每人次试验的eGFR测量中位数为7次（四分位间距4 - 12次）。AVF组和非AVF组之间eGFR下降斜率无显著差异（组间差异为-0.67 mL/min/1.73 m²/年，95%CI为-1.43，0.10）。AVF组的5年透析绝对风险为87%（95%CI为84，91），非AVF组为75%（95%CI为73，77）；AVF组的5年生存概率为77%（95%CI为70，83），非AVF组为67%（95%CI为64，69）。
在这项针对晚期慢性肾病患者的研究中，没有证据表明AVF形成具有肾脏保护作用。
