Maiorca R, Cancarini G C, Brunori G, Zubani R, Camerini C, Manili L, Movilli E
Chair of Nephrology, University of Brescia; Italy.
Adv Perit Dial. 1996;12:79-88.
We have reviewed the literature and our own center's results for patients on long-term continuous ambulatory peritoneal dialysis (CAPD) in comparison to results for patients on hemodialysis (HD). Contrary to recent American data showing one-year survivals to be worse on CAPD, the Canadian Registry and other studies show no significant difference in survivals on the two methods. Results are also conflicting for diabetics. Insufficient adjustments for age and case-mix variations are probably the most important causes for differences. For the general population, personal Cox-adjusted data show no difference between CAPD and HD up to ten-year follow-up, with very close curves for the adults and non-significant differences for the elderly. Old elderly (> 75 years) have better survival on CAPD in the first years of treatment. Dropout, which is higher on CAPD, decreases with age, and the patient retention on CAPD is worse than on HD for all patients, except the old elderly, for whom it is similar. These data were obtained in patients receiving a standard treatment, modified in order to give a more adequate dialysis dose only in recent years. The results of a prospective three-year study on the effect of nutritional [serum albumin and transferrin, normalized protein catabolic rate (PCRN), and subjective global assessment of malnutrition] and adequacy indices [Kt/V, creatinine clearance (Ccr), residual renal function] on patient survival on CAPD and HD are reported. Survival was not different for the two methods. Using the Cox analysis, nutritional indices did not affect survival whereas adequacy indices did. The effect of low serum albumin on survival was referable to the predialysis nutritional state. The similar survivals obtained on CAPD and HD, with Kt/V more or less than 1.0/treatment for HD and 1.7/week for CAPD, support the "peak concentration hypothesis" of Keshaviah et al. Survival in different groups of patients with different Kt/V and Ccr shows that the adequate dose on CAPD is Kt/V between 1.96 and 2.03 and Ccr > or = 70 L/week. A group of 26 patients who remained on CAPD treatment for more than eight years was also studied. Patient age and predialysis comorbidity were the most important factors affecting survival. Patients surviving longest had > 3 g/dL of serum albumin, > 0.8 g/kg/day of PCRN, a Kt/V > 1.6, and a weekly Ccr > 54L/week.
我们回顾了相关文献以及我们自己中心针对长期持续性非卧床腹膜透析（CAPD）患者的研究结果，并与血液透析（HD）患者的结果进行了比较。与美国近期显示CAPD患者一年生存率较差的数据相反，加拿大登记处和其他研究表明，两种方法的生存率没有显著差异。糖尿病患者的结果也存在矛盾。年龄和病例组合差异调整不足可能是造成差异的最重要原因。对于普通人群，个人经考克斯调整的数据显示，在长达十年的随访中，CAPD和HD之间没有差异，成年人的曲线非常接近，老年人的差异不显著。高龄老年人（>75岁）在治疗的头几年中，CAPD的生存率更高。CAPD的退出率较高，且随年龄增长而降低，除高龄老年人外，所有患者在CAPD治疗中的患者保留率均低于HD，而高龄老年人的情况则相似。这些数据是在接受标准治疗的患者中获得的，近年来仅对标准治疗进行了修改，以提供更充足的透析剂量。本文报告了一项为期三年的前瞻性研究结果，该研究探讨了营养指标[血清白蛋白和转铁蛋白、标准化蛋白分解代谢率（PCRN）以及营养不良的主观整体评估]和充分性指标[Kt/V、肌酐清除率（Ccr）、残余肾功能]对CAPD和HD患者生存率的影响。两种方法的生存率没有差异。使用考克斯分析，营养指标不影响生存率，而充分性指标则有影响。低血清白蛋白对生存率的影响归因于透析前的营养状态。CAPD和HD获得的相似生存率，HD每次治疗的Kt/V约为1.0，CAPD每周的Kt/V为1.7，这支持了凯沙维亚等人的“峰值浓度假说”。不同Kt/V和Ccr的不同患者组的生存率表明，CAPD的充足剂量为Kt/V在1.96至2.03之间，Ccr≥70L/周。还对一组26名持续接受CAPD治疗超过八年的患者进行了研究。患者年龄和透析前合并症是影响生存率的最重要因素。存活时间最长的患者血清白蛋白>3g/dL，PCRN>0.8g/kg/天，Kt/V>1.6，每周Ccr>54L/周。
