Maiorca R, Brunori G, Zubani R, Cancarini G C, Manili L, Camerini C, Movilli E, Pola A, d'Avolio G, Gelatti U
Nephrology, University of Brescia, Italy.
Nephrol Dial Transplant. 1995 Dec;10(12):2295-305. doi: 10.1093/ndt/10.12.2295.
The effects of dialysis inadequacy on patient survival and nutritional status and that of malnutrition on survival have not been clearly assessed. Studies comparing dose/mortality and morbidity curves on continuous ambulatory peritoneal dialysis (CAPD) and on haemodialysis (HD) are also needed, to assess adequate treatment on CAPD.
We have evaluated the effects of age, 13 pretreatment risk factors, serum albumin, transferrin, normalized protein catabolic rate, Kt/V, normalized weekly creatinine clearance, residual renal function and subjective global assessment of nutritional status on survival and morbidity, in a 3-year prospective study of 68 CAPD and 34 HD patients.
Survivals did not differ for CAPD and HD patients. In the Cox hazard regression model, age, peripheral vasculopathy, serum albumin < 3.5 g/dl and Kt/V < 1.0/treatment on HD and < 1.7/week on CAPD were independent factors negatively affecting survival. On the contrary, adjusted survivals were not affected by gender, modality, other comorbid factors, normalized protein catabolic rate, or subjective global assessment of nutritional status. Persistence of residual renal function significantly improved survival. Observed and adjusted survival did not significantly differ for CAPD and HD patients with either low (HD, < 1.0/treatment; CAPD, < 1.7/week) or high ( > or = 1.0 and > or = 1.7) Kt/V. On HD, adjusted survivals were similar for 1.0 < or = Kt/V < 1.2 or > or = 1.2. On CAPD, Kt/V > or = 1.96/week was associated with definitely better survival, with only one death/23 patients versus 19/45, with Kt/V < or = 1.96. Survival was not different for 1.96 < or = Kt/V < 2.03 and > or = 2.03. Normalized weekly creatinine clearance and wKt/V were positively related on CAPD (r 0.39, P < 0.01) and wKt/V = 1.96 corresponded to 58 litres of normalized weekly creatinine clearance.
Indices of adequacy were predictors of mortality and morbidity, both on CAPD and HD, whereas normalized protein catabolic rate and subjective global assessment of nutritional status were not. Serum albumin did not decrease during dialysis; hence its predictive effect for survival is due to the predialysis condition and not to dialysis-induced malnutrition.
透析不充分对患者生存及营养状况的影响，以及营养不良对生存的影响尚未得到明确评估。还需要对持续性非卧床腹膜透析（CAPD）和血液透析（HD）的剂量/死亡率及发病率曲线进行比较研究，以评估CAPD的充分治疗情况。
在一项对68例CAPD患者和34例HD患者进行的为期3年的前瞻性研究中，我们评估了年龄、13种治疗前危险因素、血清白蛋白、转铁蛋白、标准化蛋白分解代谢率、Kt/V、标准化每周肌酐清除率、残余肾功能以及营养状况的主观全面评估对生存和发病的影响。
CAPD和HD患者的生存率无差异。在Cox风险回归模型中，年龄、外周血管病变、血清白蛋白<3.5 g/dl以及HD治疗时Kt/V<1.0和CAPD每周Kt/V<1.7是对生存有负面影响的独立因素。相反，调整后的生存率不受性别、透析方式、其他合并症因素、标准化蛋白分解代谢率或营养状况主观全面评估的影响。残余肾功能的持续存在显著改善了生存率。Kt/V低（HD，<1.0/次治疗；CAPD，<1.7/周）或高（≥1.0和≥1.7）的CAPD和HD患者，其观察到的和调整后的生存率无显著差异。在HD中，1.0≤Kt/V<1.2或≥1.2时调整后的生存率相似。在CAPD中，Kt/V≥1.96/周与明显更好的生存率相关，Kt/V≥1.96的23例患者中仅1例死亡，而Kt/V≤1.96的45例患者中有19例死亡。1.96≤Kt/V<2.03和≥2.03时生存率无差异。CAPD中标准化每周肌酐清除率和wKt/V呈正相关（r=0.39，P<0.01），wKt/V=1.96相当于标准化每周肌酐清除率58升。
充分性指标是CAPD和HD中死亡率和发病率的预测因素，而标准化蛋白分解代谢率和营养状况主观全面评估则不是。透析过程中血清白蛋白未降低；因此其对生存的预测作用归因于透析前状况，而非透析引起的营养不良。
