Impact of timing of initiation of dialysis on mortality
Impact of timing of initiation of dialysis on mortality
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DOI：
10.1097/01.asn.0000080184.67406.11
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发表时间：
2003-09-01
影响因子：
13.6
通讯作者：
Cheung, AK
中科院分区：
文献类型：
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作者：
Beddhu, S;Samore, MH;Cheung, AK
先前的研究表明，根据修改的肾脏疾病饮食(MDRD)公式估计，病情较重的患者在较高的GFR时开始透析。以往的研究表明，低肌酐产生的患者在开始透析时营养不良，血清肌酐水平和肌酐清除率(CrCl)较低，但MDRD GFR较高。因此，我们使用倾向评分法来检验MDRD、GFR和透析开始时测量的CrCl与随后的死亡率之间的关系。基线数据和结果来自透析死亡率研究波II。通过Logistic回归得出的早期启动倾向评分在COX模型中用于检查死亡率。在整个队列中，在开始透析时，MDRD GFR每增加5ml/分钟，多变量COX模型中死亡风险就会增加(风险比[HR]1.14；P=0.002)。在报告的慢性氯化患者亚组中，MDRD GFR升高与死亡风险增加相关(每增加5ml/分钟，HR1.27；P<；0.001)，但与CrCl值无关(每增加5ml/分钟，HR0.98；P=0.81)。这些不同的结果可能反映了MDRD公式对GFR的错误估计。此外，这些数据不支持更早开始透析。因此，对于没有启动透析的临床指征的患者，启动透析的合适GFR水平是未知的。
Previous studies showed that sicker patients were initiated on dialysis at higher GFR as estimated by the Modification of Diet in Renal Disease (MDRD) formula. It was previously shown that patients with low creatinine production were malnourished and had low serum creatinine levels and creatinine clearances (CrCl) but high MDRD GFR at initiation of dialysis. Therefore, a propensity score approach was used to examine the associations of MDRD GFR and measured CrCl at the initiation of dialysis with subsequent mortality. Baseline data and outcomes were obtained from the Dialysis Morbidity Mortality Study Wave II. Propensity scores for early initiation derived by logistic regression were used in Cox models to examine mortality. Each 5-ml/min increase in MDRD GFR at initiation of dialysis in the entire cohort was associated with increased hazard of death in multivariable Cox model (hazard ratio [HR] 1.14; P = 0.002). In the subgroup of patients with reported CrCl, higher MDRD GFR was associated with increased risk of death (for each 5-ml/min increase, HR 1.27; P < 0.001) but not CrCl (for each 5-ml/min increase, HR 0.98; P = 0.81). These divergent results might reflect erroneous GFR estimation by the MDRD formula. Furthermore, these data do not support earlier initiation of dialysis. Therefore, for patients without clinical indications for initiation of dialysis, the appropriate GFR level for initiation of dialysis is unknown.