Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease
Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease
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DOI：
10.1001/jama.2022.19626
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发表时间：
2022-11-03
影响因子：
120.7
通讯作者：
Lin, Eugene
中科院分区：
文献类型：
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作者：
Fielding-Singh, Vikram;Vanneman, Matthew W.;Lin, Eugene
重要性对于接受血液透析治疗的终末期肾病患者，在选择性外科手术之前进行血液透析的最佳时机尚不清楚。目的评估血液透析和随后的外科手术之间的较长间隔是否与接受血液透析治疗的终末期肾病患者的较高术后死亡率相关。回顾性队列研究，包括346828名接受血液透析治疗的终末期肾病医疗保险受益人中的1147846例手术，这些受益人在2011年1月1日至2018年9月30日期间接受了外科手术。随访于2018年12月31日结束。暴露最近一次血液透析治疗与外科手术之间的间隔为1天、2天或3天。手术当天进行血液透析与手术当天不进行血液透析的比较。主要结局和指标主要结局是术后90天死亡率。使用考克斯比例风险模型对透析至手术间隔与主要结局之间的关系进行建模。（中位年龄，65岁[IQR，56-73岁];女性患者中495 126例手术[43.1%]，750 163例（65.4%）在手术前1天进行最后一次血液透析，285 939最后一次血液透析发生在手术前2天时为111 744例（24.9%），最后一次血液透析发生在手术前3天时为111 744例（9.7%）。193277例手术（16.8%）在手术当天还进行了血液透析。在34944例手术（3.0%）后发生了90天的术后死亡。最后一次血液透析与手术之间的间隔时间越长，90天死亡率的风险越高，且呈剂量依赖性（2天vs 1天：绝对风险，4.7% vs 4.2%，绝对风险差，0.6%[95% CI，0.4%至0.8%]，校正风险比[HR]，1.14 [95% CI，1.10至1.18]; 3天vs 1天：绝对风险，5.2% vs 4.2%，绝对风险差，1.0% [95% CI，0.8%-1.2%]，校正HR，1.25 [95% CI，1.19 - 1.31]; 3天vs 2天：绝对风险，5.2% vs 4.7%，绝对风险差异，0.4%[95% CI，0.2%至0.6%]，校正HR，1.09 [95% CI，1.04至1.13]）。与手术当天进行血液透析相比，当天未进行血液透析的患者死亡风险显著降低（绝对风险，当天血液透析为4.0% vs当天未进行血液透析为4.5%;绝对风险差异，-0.5% 95% CI，-0.7%至-0.3%];校正HR，0.88 [95% CI，0.84-0.91]）。在评估血液透析至手术间隔和同一天血液透析之间相互作用的分析中，在手术当天接受血液透析显著降低了与较长血液透析至手术间隔相关的风险（P
IMPORTANCE For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown.OBJECTIVE To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018.EXPOSURES One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure.MAIN OUTCOMES AND MEASURES The primary outcomewas 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model.RESULTS Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6%[95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4%[95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5%[95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P