Unraveling the ultrafiltration rate--mortality association in dialysis patients

描述（申请人提供）：在美国有超过35万的维持性血液透析患者，每周三次。这些患者的生存率极低，死亡率比一般人群高出10倍以上。先前的研究表明，透析实践的改变，如更温和的超滤率（UFR）可能提高生存率。UFR由必须排出的液体量（在稳定状态下等于透析期间的体重增加；IDWG）和排出液体的时间（透析时间长度；DSL）决定，这两者似乎都与死亡率有关。本项目旨在阐明DSL和IDWG与死亡率之间的独立关联。一项匹配的回顾性队列分析纳入了全国代表性的流行慢性、每周三次血液透析患者（n= 10,000），随访时间为5年：1)通过分析与DSL不一致但DSL相同的参与者配对对，估计与DSL无关的DSL与死亡率之间的关联；2)通过分析与DSL不一致但DSL相同的参与者配对对，估计与DSL无关的DSL与死亡率之间的关联。选择了一个匹配的研究设计，以便在分析IDWG时完全控制DSL，在分析DSL时完全控制IDWG，从而能够准确估计两者与生存率的独立关联。研究结果将指导临床实践和指导未来的研究。除了了解DSL和IDWG与死亡率之间的独立关系外，该项目还将评估患者采取干预措施的意愿，这些干预措施旨在通过有针对性的液体管理操作改善健康和生存。之前没有研究评估患者是否愿意在每周透析三次的情况下延长DSL。其他未经测试的IDWG控制方法包括透析间期腹膜透析和可穿戴超滤装置确实存在。将开发并验证一种仪器，以评估患者坚持液体/盐限制的意愿，采用辅助透析腹膜透析，利用可穿戴超滤设备，并扩展DSL作为减少快速UFR需求的方法。然后，该仪器将用于调查5,000名随机选择的血液透析门诊患者的态度，这些患者来自新英格兰终末期肾病网络。应对措施将为临床实践提供信息，并指导未来减少体积的研究。

DESCRIPTION (provided by applicant): There are over 350,000 maintenance thrice-weekly hemodialysis patients in the United States. These patients have exceptionally poor survival with mortality rates exceeding those of the general population by greater than 10-fold. Prior research has suggested that modifications in dialytic practice such as gentler ultrafiltration rates (UFR) may improve survival. UFR is determined by both the amount of fluid that must be removed (which at steady state equals the inter-dialytic weight gain; IDWG) and the time over which this fluid is removed (dialysis session length; DSL), each of which are plausibly associated with mortality. This project seeks to elucidate the independent associations between DSL and IDWG and mortality. A matched, retrospective cohort analysis of a nationally representative population of prevalent chronic, thrice weekly hemodialysis patients (n= 10,000) with follow-up time of 5 years will be used to: 1) estimate the association between IDWG and mortality, independent of DSL, through analysis of matched pairs of participants with discordant IDWG but identical DSL, and 2) estimate the association between DSL and mortality, independent of IDWG, through analysis of matched pairs of participants with discordant DSL but identical IDWG. A matched study design has been chosen to allow for complete control of DSL in analyses of IDWG and for IDWG in analyses of DSL to enable accurate estimation of the independent association of each with survival. Findings will inform modifications to clinical practice and direct future research. In addition to understanding the independent relationships of DSL and IDWG and mortality, the project will assess patients' willingness to adopt interventions aimed at improving health and survival through targeted manipulations of fluid management. No prior research has assessed patient willingness to extend DSL in response to volume considerations within the context of thrice weekly dialysis. Other untested methods of IDWG control including interdialytic peritoneal dialysis and wearable ultrafiltration devices do exist. An instrument will be developed and validated to assess patient willingness to adhere to fluid/salt restrictions, adopt adjunct interdialytic peritoneal dialysis, utilize wearable ultrafiltration devices, and extend DSL as methods to minimize need for rapid UFR. This instrument will then be used to survey attitudes of 5,000 randomly selected hemodialysis outpatients from the End Stage Renal Disease Network of New England. Responses will inform clinical practice and guide future research in volume mitigation.