Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: A reanalysis of the CANUSA study
Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: A reanalysis of the CANUSA study
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DOI：
10.1681/asn.v12102158
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发表时间：
2001-10-01
影响因子：
13.6
通讯作者：
Churchill, DN
中科院分区：
文献类型：
--
作者：
Bargman, JM;Thorpe, KE;Churchill, DN
关于腹膜透析充分性的研究及相关建议都假定肾清除率和腹膜清除率具有可比性，因此是可相加的。为了验证这一假定，对加拿大-美国（CANUSA）的数据进行了重新分析。在最初的CANUSA研究的680名患者中，601名患者具备本报告所关注的所有变量。通过肾小球滤过率（肾尿素和肌酐清除率的平均值）以及腹膜肌酐清除率来评估透析的充分性。采用Cox比例风险模型来评估这些自变量与患者生存率之间的时间依赖性关联。肾小球滤过率每1.73平方米每周每增加5升，死亡相对风险（RR）降低12%（RR，0.88；95%置信区间[CI]，0.83 - 0.94），但与腹膜肌酐清除率无关联（RR，1.00；95% CI，0.90 - 1.10）。然后将液体清除量的估算值（24小时尿量、腹膜净超滤量和总液体清除量）加入到Cox模型中。尿量每增加250毫升，死亡RR降低36%（RR，0.64；95% CI，0.51 - 0.80）。患者生存率与肾小球滤过率之间的关联消失（RR，0.99；95% CI，0.94 - 1.04）。然而，腹膜净超滤量和总液体清除量均与患者生存率无关。尽管从统计学角度来看，这些结果可能部分是由于腹膜清除率的变异性小于肾小球滤过率，但从生理学角度来看，后者似乎比前者更为重要。这些数据不支持腹膜清除率和肾清除率等效的这一假定。鉴于这些观察结果，需要对腹膜透析充分性的相关建议进行重新评估。
Studies of the adequacy of peritoneal dialysis and recommendations have assumed that renal and peritoneal clearances are comparable and therefore additive. The CANUSA data were reanalyzed in an effort to address this assumption. Among the 680 patients in the original CANUSA study, 601 had all of the variables of interest for this report. Adequacy of dialysis was estimated from GFR (mean of renal urea and creatinine clearance) and from peritoneal creatinine clearance. The Cox proportional-hazards model was used to evaluate the time-dependent association of these independent variables with patient survival. For each 5 L/wk per 1.73 m(2) increment in GFR, there was a 12% decrease in the relative risk (RR) of death (RR, 0.88: 95% confidence interval [CI], 0.83 to 0.94) but no association with peritoneal creatinine clearance (RR, 1.00; 95% CI. 0.90 to 1.10). Estimates of fluid removal (24-h urine volume, net peritoneal ultrafiltration, and total fluid removal) then were added to the Cox model. For a 250-ml increment in urine volume, there was a 36% decrease in the RR of death (RR, 0.64; 95% CI, 0.51 to 0.80). The association of patient survival with GFR disappeared (RR. 0.99; 95% CI, 0.94 to 1.04). However. neither net peritoneal ultrafiltration nor total fluid removal was associated with patient survival. Although these results may be explained partly, statistically, by less variability in peritoneal clearance than in GFR, the latter seems to be physiologically more important than the former. The assumption of equivalence of peritoneal and renal clearances is not supported by these data. Recommendations for adequate peritoneal dialysis need to be reevaluated in light of these observations.