Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival
Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival
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DOI：
10.1038/ki.2010.14
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发表时间：
2010-04-01
影响因子：
19.6
通讯作者：
Stengel, Benedicte
中科院分区：
文献类型：
--
作者：
Lassalle, Mathilde;Labeeuw, Michel;Stengel, Benedicte
在几个国家，患者早期开始透析的发生率一直在增加。然而，一些研究质疑其效用，发现当以较高的估计肾小球滤过率（eGFR）开始透析时，死亡率增加的反直觉效应。为了更详细地研究这一问题，我们测量了来自法国REIN登记研究的11,685例患者在透析开始时与肾脏疾病饮食调整eGFR相关的死亡风险比，并对一些协变量进行了序贯调整。eGFR通过每1.73 m2增量5 ml/min和10/10（即，第15个十分位数，包括每1.73 m（2）10 ml/min左右的值，是我们的参考点。更有可能以较高eGFR开始开始透析的患者是老年男性患者;患有糖尿病、心血管疾病或低体重指数和白蛋白血症水平;或开始腹膜透析。在中位随访21.9个月期间，3945名患者死亡。2年粗生存率从79%下降到46%，eGFR从每1.73 m2小于5 ml/min增加到20 ml/min以上。eGFR每增加5 ml/min/1.73 m2，粗死亡风险增加40%，粗死亡风险降低至9%，但在调整上述协变量后仍具有统计学显著性。通过十分位数的分析显示，只有最高的风险显着更高。因此，我们发现年龄和患者状况强烈决定开始透析的决定，并可能解释eGFR和生存率之间的大部分负相关。Kidney International（2010）77，700-707; doi：10.1038/ki.2010.14; 2010年2月10日在线发表
Starting patients on dialysis early has been increasing in incidence in several countries. However, some studies have questioned its utility, finding a counter-intuitive effect of increased mortality when dialysis was started at a higher estimated glomerular filtration rate (eGFR). To examine this issue in more detail we measured mortality hazard ratios associated with Modification of Diet in Renal Disease eGFR at dialysis initiation for 11,685 patients from the French REIN Registry, with sequential adjustment for a number of covariates. The eGFR was analyzed both quantitatively by 5-ml/min per 1.73 m(2) increments and by demi-decile (i.e., 5 percentiles of the distribution); the 15th demi-decile, including values around 10ml/min per 1.73 m(2), was our reference point. The patients more likely to begin dialysis at a higher eGFR were older male patients; had diabetes, cardiovascular diseases, or low body mass index and level of albuminemia; or were started with peritoneal dialysis. During a median follow-up of 21.9 months, 3945 patients died. The 2-year crude survival decreased from 79 to 46%, with increasing eGFR from less than 5 to over 20 ml/min per 1.73 m(2). Each 5-ml/min/1.73 m(2) increase in eGFR was associated with a 40% increase in crude mortality risk, which weakened to 9%, but remained statistically significant after adjusting for the above covariates. Analysis by demi-decile showed only the highest to be at significantly higher risk. Hence we found that age and patient condition strongly determine the decision to start dialysis and may explain most of the inverse association between eGFR and survival. Kidney International (2010) 77, 700-707; doi:10.1038/ki.2010.14; published online 10 February 2010