The dose of hemodialysis and patient mortality
The dose of hemodialysis and patient mortality
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DOI：
10.1038/ki.1996.348
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发表时间：
1996-08-01
影响因子：
19.6
通讯作者：
Hakim, RM
中科院分区：
文献类型：
--
作者：
Held, PJ;Port, FK;Hakim, RM
血液透析的剂量与患者死亡率之间的关系仍然存在一定的争议。几项观察性研究表明，较高水平的透析剂量可以改善患者的存活率。然而，其他几个未测量的变量、患者组合的变化或医疗管理可能对报告的死亡率差异产生了影响。目前的研究对来自347个透析单位的2311名美国全国患者样本进行了评估，估计了血液透析剂量与死亡率的关系，并对广泛的并发症/风险因素进行了统计调整。此外，这项研究还调查了存在一个剂量，超过这个剂量，透析次数越多似乎不会降低死亡率。我们使用比例风险回归技术，对9个人口普查地区的21个患者共病/危险因素进行分层调整，以评估患者的存活率。患者样本为2：311名患有终末期肾病至少一年的联邦医疗保险血液透析患者，截至1990年12月31日，使用碳酸氢盐透析液进行治疗。患者随诊时间为1.5~2.4年。治疗剂量的测量基于两种可供选择的透析内尿素减少指标，尿素减少比(URR)和Kt/V(调整或尿素生成和超滤)；无论是以Kt/V衡量，还是以URR衡量，血液透析患者的病死率都与血液透析剂量呈强烈的负相关。分娩的Kt/V每增加0.1%，死亡风险降低7%(P=0.001)(以URR表示，死亡率每增加5个百分点，死亡率降低11%；P=0.001)。超过70%的URR或1.3的Kt/V，这些数据没有提供进一步降低死亡率的统计证据。总而言之。血液透析治疗的剂量是患者死亡率的重要预测因素。在死亡率非常高的透析患者群体中，提高治疗水平似乎提供了一种实用而有效的降低死亡率的方法-以URR或Kt/V衡量的血液透析剂量水平，超过这一水平死亡率不会继续下降，尽管本研究没有很好地定义，但似乎高于美国血液透析患者目前的典型治疗水平。
The relationship between the delivered dose of hemodialysis and patient mortality remains somewhat controversial. Several observational studies have shown improved patient survival with higher levels of delivered dialysis dose. However, several other unmeasured variables,changes in patient mix or medical management may have impacted on this reported difference in mortality. The current study of a U.S. national sample of 2,311 patients from 347 dialysis units estimates the relationship of delivered hemodialysis dose to mortality, with a statistical adjustment for an extensive list of comorbidity/risk factors, Additionally this study investigated the existence of a dose beyond which more dialysis does not appear to lower mortality. We estimated patient survival using proportional hazards regression techniques, adjusting or 21 patient comorbidity/risk factors with stratification for nine Census regions. The patient ample was 2:311 Medicare hemodialysis patients treated with bicarbonate dialysate as of 12/31/90 who had end-stage renal disease for at least one year. Patient follow-up ranged between 1.5 and 2.4 years. The measurement of delivered therapy was based on two alternative measures of intradialytic urea reduction, the urea reduction ratio (URR) and Kt/V (with adjustment or urea generation and ultrafiltration); Hemodialysis patient mortality showed a strong and robust inverse correlation with delivered hemodialysis dose whether measured by Kt/V or by URR. Mortality risk was lower by 7% (P = 0.001) with each 0.1 higher level of delivered Kt/V. (Expressed in terms URR, mortality was lower by 11% with each 5 percentage point higher URR; P = 0.001). Above a URR of 70% or a Kt/V of 1.3 these data did not provide statistical evidence of further reductions in mortality. In conclusion. the delivered dose of hemodialysis therapy is an important predictor of patient mortality. In a population of dialysis patients with a very high mortality rate, it appears that increasing the level of delivered therapy offers a practical and efficient means of lowering the mortality rare-The level of hemodialysis dose measured by URR or Kt/V beyond which the mortality rate does not continue to decrease, though not well defined with this study, appears to be above current levels of typical treatment of hemodialysis patients in the U.S.