Maintaining residual renal function in patients on haemodialysis: 5-year experience using a progressively increasing dialysis regimen
Maintaining residual renal function in patients on haemodialysis: 5-year experience using a progressively increasing dialysis regimen
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DOI：
10.3265/nefrologia.pre2012.jul.11517
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发表时间：
2012-01-01
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影响因子：
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通讯作者：
Quereda-Rodríguez-Navarro, Carlos
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作者：
Fernández-Lucas, Milagros;Teruel-Briones, José L.;Quereda-Rodríguez-Navarro, Carlos
导言：与腹膜透析治疗的患者相比，定期血液透析(HD)患者的透析量不会按程序递增，在计算总透析处方时也不考虑残余肾功能；相反，公式中只考虑透析器的清除。2006年，我们决定在肾脏替代治疗开始时建立逐步递增的透析方案，评估当肾脏尿素清除量等于或大于2.5ml/min时开始2次HD/周的可能性。这项研究总结了我们在应用这一递增HD处方的前5年的经验及其对残余肾功能的影响。方法：纳入2006年1月1日至2010年9月30日期间开始定期透析并维持透析3个月以上的所有患者。跟踪期于2010年12月31日(研究结束日)结束。当患者开始透析时，根据透析前采集的血液样本和开始每周第一次透析前24小时的尿样中的尿素和肌酐浓度来测量尿素和肌酐清除水平。如果尿素清除量等于或大于2.5ml/min，只要患者的临床情况允许(根据主治医生的标准)，每周应用2次HD。每2个月分析一次残余肾功能，直到利尿少于100ml/天，被认为基本为零。我们评估残余肾功能的下降，计算每周接受2次和3次HD的患者的肾小球滤过率(ml/min/月)和24小时利尿率(ml/月)。2010年1月，我们采取了横断面样本，评估了每周接受2次或3次透析的患者的肾小球滤过率及其与各种临床和实验室参数之间的关系。结果：在研究期间，95名患者纳入研究，其中41例(43%)开始每周2次HD，54例(57%)每周3次。患者每周坚持2HD疗程的平均时间为11.1+/-7.2个月(范围：2-25个月)。在41例患者中，10例在治疗方案中接受了移植，其中1例转到腹膜透析，6例肾功能恢复并能够放弃透析治疗，15例切换到每周3次HD方案，9例在研究结束时继续接受2次HD方案。在切换到每周3次HD方案的15名患者中，4人接受了移植，3人死亡，其余8人继续接受HD治疗，直到研究结束。卡普兰-迈耶生存分析显示，开始接受2次HD疗程/周方案的患者存活率更高(LOG-RANK：3.964；P=0.04)。每周2次HD方案的患者肾小球滤过率丢失和24小时利尿发生率较低：肾小球滤过率0.22+/-0.36ml/分钟/月比0.89+/-1.26ml/分钟/月(P=0.001)；24小时利尿90.59±/-132ml/月比206.23+/-286ml/月(P=0.001)。在2010年1月采集的横断面样本中，17名患者接受2次HD/周方案，47名患者接受3次HD/周方案。每周透析2次组的血清β2-微球蛋白浓度显著低于对照组(19.7+/-5vs 38.3+/-13；P=.000)。两组患者的平均血红蛋白浓度相似，但每周透析2次组患者所需促红细胞生成素的剂量明显较低(7058 3749单位/周vs 12 553 10 826单位/周；P=.037)。结论：在选择的人群中，HD的开始可以逐步增加剂量，从每周两次开始。根据我们的经验，这是一种安全的处方，可能有助于保留残余肾功能。
Introduction: In contrast to patients treated with peritoneal dialysis, those on periodical haemodialysis (HD) do not receive programmed progressive increases in dialysis dosage, nor is residual renal function taken into account in the calculation of the total dialysis prescription; rather, only dialyser clearance is factored into the equation. In 2006, we decided to establish a progressively increasing dialysis regimen at the start of renal replacement therapy, evaluating the possibility of starting with 2 sessions of HD/week when renal clearance of urea was equal to or greater than 2.5ml/min. This study summarises our experience during the first 5 years of application of this progressively increasing HD prescription and its repercussions on residual renal function. Methods: We included all patients who started periodical HD between 1/1/2006 and 30/9/2010 and remained on dialysis for more than three months. The follow-up period ended on 31/12/2010 (study end date). When a patient started HD, urea and creatinine clearance levels were measured based on urea and creatinine concentrations in blood samples taken before dialysis and in urine samples taken 24 hours prior to starting the first dialysis session of the week. If urea clearance was equal to or greater than 2.5ml/min, 2 sessions of HD per week were applied, as long as the patient's clinical situation allowed for it (according to the criteria of the attending physician). Residual renal function was analysed every 2 months until diuresis was less than 100ml/day, which is considered to be basically null We evaluated the decrease in residual renal function, calculating the rate of decrease in glomerular filtration (ml/min/month) and 24-hour diuresis (ml/month) in patients receiving 2 and 3 HD sessions per week. In January 2010, we took a cross-sectional sample, evaluating glomerular filtration and how this value was associated with various clinical and laboratory parameters in patients receiving 2 or 3 dialysis sessions per week. Results: During the study period, 95 patients were included in the study, 41 of which (43%) started with 2 HD sessions per week, and 54 (57%) with 3 sessions per week. The mean time that patients remained on the 2HD sessions/week regimen was 11.1 +/- 7.2 months (range: 2-25 months). Of the 41 patients that started with 2 HD sessions/week, 10 received a transplant while on the treatment regimen, 1 was transferred to peritoneal dialysis, 6 recovered renal function and were able to abandon dialysis treatment, 15 were switched to the 3 HD sessions/week regimen, and 9 continued on the 2 HD sessions/week regimen at the time the study ended. Of the 15 patients that were switched to the 3 HD sessions/week regimen, 4 received transplants, 3 died, and the remaining 8 continued on HD until the end of the study. A Kaplan-Meier survival analysis revealed that patients who started on the 2 HD sessions/week regimen had a greater survival rate (log-rank: 3.964; P=.04). Loss in glomerular filtration rate and 24-hour diuresis was lower in patients on the 2 HD sessions/week regimen: 0.22 +/- 0.36ml/min/month vs 0.89 +/- 1.26ml/min/month for glomerular filtration (P=.001), and 90.59 +/- 132ml/month vs 206.23 +/- 286ml/month for 24-hour diuresis (P=.001). In the cross-sectional sample taken in January 2010, 17 patients were on the 2 HD sessions/week regimen and 47 were on the 3 HD sessions/week regimen. Serum concentrations of beta 2-microglobulin were significantly lower in the 2 HD sessions/week group (19.7 +/- 5 vs 38.3 +/- 13; P=.000).The mean haemoglobin concentration was similar between the two groups, with a significantly lower dose required of erythropoietin in patients on the 2 HD sessions/week regimen (7058 3749 units/week vs 12 553 10 826 units/week; P=.037). Condusion: In select populations, the start of HD can be administered on a progressively increasing dosage, starting with two sessions/week. In our experience, this is a safe prescription that probably contributes to preserving residual renal function.