Ifudu O, Paul H R, Homel P, Friedman E A
Department of Medicine, State University of New York Health Science Center at Brooklyn, USA.
Am J Nephrol. 1998;18(2):109-16. doi: 10.1159/000013318.
In patients receiving maintenance hemodialysis, laboratory indices (such as serum albumin concentration) are predominantly utilized to assess well-being, while measures of functional status are rarely applied. However, the serum albumin concentration declines with advancing age, and the mean age of patients starting maintenance hemodialysis is now over 63 years. Using a 14-level modified Karnofsky activity scale, we measured baseline functional status in 522 randomly selected hemodialysis patients and prospectively monitored them for 3 years to determine the predictive value of our modified Karnofsky score for mortality. At onset of study, serum albumin and creatinine concentrations as well as hematocrit were measured and the comorbid conditions documented. At baseline, the 522 subjects (270 women and 252 men) included 327 blacks (63%), 154 whites (29%), 31 Hispanics (6%), and 10 Asians (2%) of mean age 59 +/- (SD) 15 years. The mean duration of end-stage renal disease was 4 +/- 3.6 years, and the mean serum albumin concentration was 3.7 +/- 0.4 g/dl. 166 (32%) of the patients died during the observation period. Cox regression analysis revealed inverse relations between mortality and both our modified Karnofsky score (p = 0.0001) and serum albumin concentration (p = 0.001). The predictive value of a low modified Karnofsky score for mortality persisted after analysis of subjects stratified according to serum albumin concentration (< 4 g/dl, n = 382, p = 0.0001 vs. > or = 4 g/dl, n = 140, p = 0.008). With a modified Karnofsky score (< 70 vs. > or = 70), the relative risk of death during the 3-year follow-up period was 1.44 (95% confidence interval 1.236, 1.675; p < 0.0001). Forward stepwise Cox regression analysis showed that advanced age (p = 0.0005), white race (p = 0.0009), diabetes mellitus (p = 0.01), and a low serum albumin concentration (p = 0.003) were independently associated with an increased risk of mortality during follow-up after adjustment for other factors. A modified Karnofsky score (p = 0.14) did not predict survival in the Cox model when other independent variables were included. We conclude that in patients with end-stage renal disease sustained on maintenance hemodialysis, a poor functional status (measured on a modified Karnofsky activity scale) is associated with early mortality. Periodic measurement of modified Karnofsky score is a simple, low-cost, and reliable means of identifying patients on dialysis at risk for early death.
在接受维持性血液透析的患者中，实验室指标（如血清白蛋白浓度）主要用于评估健康状况，而功能状态的评估方法很少应用。然而，血清白蛋白浓度会随着年龄的增长而下降，目前开始接受维持性血液透析的患者平均年龄超过63岁。我们使用14级改良卡诺夫斯基活动量表，对522例随机选择的血液透析患者的基线功能状态进行了测量，并对他们进行了为期3年的前瞻性监测，以确定我们改良的卡诺夫斯基评分对死亡率的预测价值。在研究开始时，测量了血清白蛋白和肌酐浓度以及血细胞比容，并记录了合并症。基线时，522名受试者（270名女性和252名男性）包括327名黑人（63%）、154名白人（29%）、31名西班牙裔（6%）和10名亚洲人（2%），平均年龄为59±（标准差）15岁。终末期肾病的平均病程为4±3.6年，平均血清白蛋白浓度为3.7±0.4 g/dl。166名（32%）患者在观察期内死亡。Cox回归分析显示，死亡率与我们改良的卡诺夫斯基评分（p = 0.0001）和血清白蛋白浓度（p = 0.001）均呈负相关。在根据血清白蛋白浓度分层的受试者分析后（< 4 g/dl，n = 382，p = 0.0001 vs.≥4 g/dl，n = 140，p = 0.008），低改良卡诺夫斯基评分对死亡率的预测价值依然存在。改良卡诺夫斯基评分（< 70 vs.≥70）时，3年随访期内死亡的相对风险为1.44（95%置信区间1.236, 1.675；p < 0.0001）。向前逐步Cox回归分析显示，在对其他因素进行调整后，高龄（p = 0.0005）、白人种族（p = 0.0009）糖尿病（p = 0.01）和低血清白蛋白浓度（p = 0.003）与随访期间死亡率增加独立相关。当纳入其他自变量时，改良卡诺夫斯基评分（p = 0.14）在Cox模型中不能预测生存率。我们得出结论，在接受维持性血液透析的终末期肾病患者中，功能状态较差（用改良卡诺夫斯基活动量表测量）与早期死亡率相关。定期测量改良卡诺夫斯基评分是一种简单、低成本且可靠的方法，可用于识别有早期死亡风险的透析患者。
