Foley R N, Parfrey P S, Harnett J D, Kent G M, O'Dea R, Murray D C, Barre P E
Division of Nephrology, The Health Sciences Centre, Memorial University, St. John's, Newfoundland, Canada.
J Am Soc Nephrol. 1998 Feb;9(2):267-76. doi: 10.1681/ASN.V92267.
Despite considerable differences in technique and blood purification characteristics, hemodialysis and peritoneal dialysis have been thought to have similar patient outcomes. An inception cohort of 433 end-stage renal disease patients was followed prospectively for a mean of 41 mo. The outcomes of hemodialysis (HD) and peritoneal dialysis (PD) patients were compared using intention to treat analysis based on the mode of therapy at 3 mo. After adjustment for PD patients less likely to have chronic hypertension and more likely to have diabetes, ischemic heart disease, and cardiac failure at baseline (P < 0.05), a biphasic mortality pattern was observed. For the first 2 yr, there was no statistically significant difference in mortality. After 2 yr, mortality was greater among PD patients with an adjusted PD/HD hazard ratio of 1.57 (95% confidence interval [CI], 0.97 to 2.53). Both the occurrence (adjusted hazards ratio 6.87 [95% CI, 2.01 to 23.5]) and the direction (toward PD, adjusted hazards ratio 6.25 [95% CI, 1.54 to 25]) of a therapy switch were subsequently associated with mortality after 2 yr. Progressive clinical and echocardiographic cardiac disease were not responsible for this late mortality. Lower mean serum albumin levels in PD patients in the first 2 yr of therapy (3.5 +/- 0.5 versus 3.9 +/- 0.5 g/dl, P < 0.0001) accounted for a large proportion of the increase in subsequent mortality. Hemodialysis has a late survival advantage over peritoneal dialysis; antecedent hypoalbuminemia is a major marker of the increased late mortality in PD patients.
尽管血液透析和腹膜透析在技术和血液净化特性方面存在显著差异，但一直以来人们认为它们对患者的治疗效果相似。对一个由433例终末期肾病患者组成的起始队列进行了平均41个月的前瞻性随访。根据3个月时的治疗方式，采用意向性治疗分析比较了血液透析（HD）和腹膜透析（PD）患者的治疗效果。在对基线时PD患者慢性高血压发生率较低、糖尿病、缺血性心脏病和心力衰竭发生率较高的情况进行校正后（P<0.05），观察到一种双相死亡模式。在最初的2年里，死亡率没有统计学上的显著差异。2年后，PD患者的死亡率更高，校正后的PD/HD风险比为1.57（95%置信区间[CI]，0.97至2.53）。治疗转换的发生率（校正风险比6.87[95%CI，2.01至23.5]）和方向（倾向于PD，校正风险比6.25[95%CI，1.54至25]）随后都与2年后的死亡率相关。进行性临床和超声心动图心脏病并非导致这种晚期死亡的原因。在治疗的前2年中，PD患者较低的平均血清白蛋白水平（3.5±0.5与3.9±0.5 g/dl，P<0.0001）在随后死亡率增加中占了很大比例。血液透析在晚期生存方面优于腹膜透析；先前的低白蛋白血症是PD患者晚期死亡率增加的主要标志。
