Activated injectable vitamin D and hemodialysis survival:: A historical cohort study
Activated injectable vitamin D and hemodialysis survival:: A historical cohort study
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DOI：
10.1681/asn.2004070573
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发表时间：
2005-04-01
影响因子：
13.6
通讯作者：
Thadhani, R
中科院分区：
文献类型：
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作者：
Teng, M;Wolf, M;Thadhani, R
ESRD患者通常会发生继发性甲状旁腺功能亢进，这种情况主要通过活化的可注射维生素D治疗。然而，维生素D的生物学效应是广泛的，活化的可注射维生素D可能会改变ESRD的存活率。这一假设在1996年1月至1999年12月期间居住在美国各地的血液透析患者的历史队列研究中进行了检验。主要结果是开始慢性血液透析后存活至少90天的患者的2年生存率。在此期间，51，037例慢性血液透析患者从血液透析开始至少存活90天，在随后的2年中，37，173例接受活化注射维生素D，13，864例未接受。2年时，注射维生素D组的死亡率为13.8/100人-年，而未注射维生素D组的死亡率为28.6/100人-年（P <0.001）。调整了几个潜在混杂因素的考克斯比例风险分析，并将注射型维生素D治疗作为时间依赖性暴露进行了研究，结果表明，与未接受注射型维生素D治疗的患者相比，接受注射型维生素D治疗的患者的2年生存率优势为20%（风险比为0.80; 95%置信区间为0.76~0.83）。注射维生素D组的心血管相关死亡率为7.6/100人年，而非维生素D组为14.6/100人年（P <0.001）。注射维生素D的益处在49个分层中的48个分层中是明显的，包括那些血清全段甲状旁腺激素水平低和血清钙和磷水平升高的人，在这些情况下，注射维生素D经常被扣留。使用边际结构模型重复整个分析，以调整适应症的时间依赖性混杂因素，与注射维生素D组相关的生存优势为26%（风险比，0.74; 95%置信区间，0.71至0.79）。在这项历史性队列研究中，接受注射维生素D的慢性血液透析患者比未接受注射维生素D的患者具有显著的生存优势。随机临床试验将得出明确的结论。
Patients with ESRD commonly experience secondary hyperparathyroidism, a condition primarily managed with activated injectable vitamin D. The biologic effects of vitamin D, however, are widespread, and it is possible that activated injectable vitamin D alters survival in ESRD. This hypothesis was tested in a historical cohort study of incident hemodialysis patients who lived throughout the United States between January 1996 and December 1999. The primary outcome was 2-yr survival among those who survived for at least 90 d after initiation of chronic hemodialysis. During this period, 51,037 chronic hemodialysis patients survived for at least 90 d from the initiation of hemodialysis, and in the ensuing 2 yr, 37,173 received activated injectable vitamin D and 13,864 did not. At 2 yr, mortality rates were 13.8/100 person-years in the group that received injectable vitamin D compared with 28.6/100 person-years in the group that did not (P < 0.001). Cox proportional hazards analyses adjusting for several potential confounders and examining injectable vitamin D therapy as a time-dependent exposure suggested that compared with patients who did not receive injectable vitamin D, the 2-yr survival advantage associated with the group that did receive injectable vitamin D was 20% (hazard ratio, 0.80; 95% confidence interval, 0.76 to 0.83). The incidence of cardiovascular-related mortality was 7.6/100 person-years in the injectable vitamin D group, compared with 14.6/100 person-years in the non-vitamin D group (P < 0.001). The benefit of injectable vitamin D was evident in 48 of 49 strata examined, including those with low serum levels of intact parathyroid hormone and elevated levels of serum calcium and phosphorus, situations in which injectable vitamin D is often withheld. Repeating the entire analysis using marginal structural models to adjust for time-dependent confounding by indication yielded a survival advantage of 26% (hazard ratio, 0.74; 95% confidence interval, 0.71 to 0.79) associated with the injectable vitamin D group. In this historical cohort study, chronic hemodialysis patients in the group that received injectable vitamin D had a significant survival advantage over patients who did not. Randomized clinical trials would permit definitive conclusions.