透析开始残余肾功能与维持性透析患者预后的关系
투석개시잔여신공능여유지성투석환자예후적관계
Association of residual renal function at initiation of dialysis with prognosis in maintenance dialysis patients
  • 万方数据
    中华肾脏病杂志 중화신장병잡지

    2012年 10期 757-764 ,共8页

    朱丽娜%吕文律%滕杰%邹建洲%刘中华%沈波%钟一红%丁小强

    주려나%려문률%등걸%추건주%류중화%침파%종일홍%정소강

    透析%肾功能%预后%并发症 透析%腎功能%預後%併髮癥
    투석%신공능%예후%병발증
    Dialysis%Renal function%Prognosis%Complications
    目的 评估终末期肾病患者透析开始残余肾功能与维持性透析预后的关系.方法 收集2005年1月1日至2009年9年30日新进入血透或腹透治疗的终末期肾病成年患者资料,随访至2010年3月31日.根据透析开始时估算肾小球滤过率(eGFR)分为≥10.5、8～＜10.5、6～＜8、＜6 ml· min-1·(1.73 m2)-1 4组.eGFR评估采用MDRD简化公式.终点事件为全因死亡和心脑血管死亡.结果 (1)共562例患者入选,透析开始中位eGFR为5.60(2.26～12.62) ml· min-1·(1.73 m2)-1;中位随访时间为17(0～58)个月 ;死亡141例,中位生存期为45.48(43.05 ～47.90)个月.随着透析开始eGFR下降,4组患者Scr、BUN、血尿酸(SUA)、血前白蛋白、血磷、血钙磷乘积、整段甲状旁腺激素(iPTH)、平均动脉压(MAP)逐渐升高 ;血红蛋白(Hb)、男性患者比例、并发糖尿病比例、Charison并发症指数≥5比例逐渐下降,差异均有统计学意义(均P＜ 0.05).随着透析开始eGFR下降,并发左室肥大比例有逐渐升高趋势,但差异无统计学意义.(2)Kaplan-Meier生存曲线显示4组患者总体生存率差异无统计学意义.Cox回归分析显示透析开始eGFR与透析预后无显著关系.对透析非早期(＞3个月)死亡患者进行Kaplan-Meier生存曲线分析,4组患者1年生存率差异无统计学意义.多因素Cox回归分析显示透析开始eGFR是透析1年生存预后的保护因素(HR =0.791,95％CI 0.669～0.935,P＜0.01).(3)以心脑血管死亡为终点事件,多因素Cox回归分析显示,透析开始eGFR是心脑血管生存预后(HR =0.868,95％CI 0.777～0.971,P＜0.05)和1年心脑血管生存预后(HR=0.937,95％CI 0.851～0.992,P＜0.05)的保护因素.(4)多因素Cox回归分析显示,透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,腹膜透析患者死亡风险下降10％(HR=0.90,95％CI 0.81～0.99,P＜ 0.05).血液透析方式4组患者Kaplan-Meier生存率分析显示,差异有统计学意义(Log-rank检验,P=0.047),8～＜10.5组生存率最低,与6～＜8组、＜6组差异有统计学意义(Log-rank检验,P=0.033,P=0.005).多因素Cox回归分析并未显示透析开始eGFR与预后相关.多因素Cox回归分析提示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者和慢性肾小球肾炎腹膜透析患者死亡风险分别降低16.6％(HR=0.834,95％CI 0.736～0.946,P＜0.01)和32.1％(HR=0.679,95％CI 0.535～0.862,P＜0.01).以心脑血管死亡为终点,多因素Cox回归分析显示透析开始eGFR增高1 ml·min-1·(1.73 m2)-1,慢性肾小球肾炎患者心脑血管死亡风险下降18.2％(HR=0.818,95％CI 0.669～0.999,P＜0.05).结论 本组患者透析时机明显晚于国际透析指南的标准.随着透析开始eGFR降低,并发症增多及程度加重.早期透析可能无法提高透析患者的总体生存率,但可能有助于改善患者心脑血管及1年总体生存预后和腹膜透析、慢性肾小球肾炎患者的预后.
    목적 평고종말기신병환자투석개시잔여신공능여유지성투석예후적관계.방법 수집2005년1월1일지2009년9년30일신진입혈투혹복투치료적종말기신병성년환자자료,수방지2010년3월31일.근거투석개시시고산신소구려과솔(eGFR)분위≥10.5、8～＜10.5、6～＜8、＜6 ml· min-1·(1.73 m2)-1 4조.eGFR평고채용MDRD간화공식.종점사건위전인사망화심뇌혈관사망.결과 (1)공562례환자입선,투석개시중위eGFR위5.60(2.26～12.62) ml· min-1·(1.73 m2)-1;중위수방시간위17(0～58)개월 ;사망141례,중위생존기위45.48(43.05 ～47.90)개월.수착투석개시eGFR하강,4조환자Scr、BUN、혈뇨산(SUA)、혈전백단백、혈린、혈개린승적、정단갑상방선격소(iPTH)、평균동맥압(MAP)축점승고 ;혈홍단백(Hb)、남성환자비례、병발당뇨병비례、Charison병발증지수≥5비례축점하강,차이균유통계학의의(균P＜ 0.05).수착투석개시eGFR하강,병발좌실비대비례유축점승고추세,단차이무통계학의의.(2)Kaplan-Meier생존곡선현시4조환자총체생존솔차이무통계학의의.Cox회귀분석현시투석개시eGFR여투석예후무현저관계.대투석비조기(＞3개월)사망환자진행Kaplan-Meier생존곡선분석,4조환자1년생존솔차이무통계학의의.다인소Cox회귀분석현시투석개시eGFR시투석1년생존예후적보호인소(HR =0.791,95％CI 0.669～0.935,P＜0.01).(3)이심뇌혈관사망위종점사건,다인소Cox회귀분석현시,투석개시eGFR시심뇌혈관생존예후(HR =0.868,95％CI 0.777～0.971,P＜0.05)화1년심뇌혈관생존예후(HR=0.937,95％CI 0.851～0.992,P＜0.05)적보호인소.(4)다인소Cox회귀분석현시,투석개시eGFR증고1 ml·min-1·(1.73 m2)-1,복막투석환자사망풍험하강10％(HR=0.90,95％CI 0.81～0.99,P＜ 0.05).혈액투석방식4조환자Kaplan-Meier생존솔분석현시,차이유통계학의의(Log-rank검험,P=0.047),8～＜10.5조생존솔최저,여6～＜8조、＜6조차이유통계학의의(Log-rank검험,P=0.033,P=0.005).다인소Cox회귀분석병미현시투석개시eGFR여예후상관.다인소Cox회귀분석제시투석개시eGFR증고1 ml·min-1·(1.73 m2)-1,만성신소구신염환자화만성신소구신염복막투석환자사망풍험분별강저16.6％(HR=0.834,95％CI 0.736～0.946,P＜0.01)화32.1％(HR=0.679,95％CI 0.535～0.862,P＜0.01).이심뇌혈관사망위종점,다인소Cox회귀분석현시투석개시eGFR증고1 ml·min-1·(1.73 m2)-1,만성신소구신염환자심뇌혈관사망풍험하강18.2％(HR=0.818,95％CI 0.669～0.999,P＜0.05).결론 본조환자투석시궤명현만우국제투석지남적표준.수착투석개시eGFR강저,병발증증다급정도가중.조기투석가능무법제고투석환자적총체생존솔,단가능유조우개선환자심뇌혈관급1년총체생존예후화복막투석、만성신소구신염환자적예후.
    Objective To examine the association between residual renal function at initiation of dialysis and prognosis in maintenance dialysis patients.Methods Incident patients with end-stage renal diseases initiating dialysis between 1 January 2005 and 30 September 2009,followed up to 31 March 2010 were enrolled in this study.Residual renal function was evaluated using eGFR estimated by the abbreviated MDRD equation.Patients were classified into four groups according to eGFR of ≥10.5,8 to ＜10.5,6 to ＜8,＜6 ml·min-1·(1.73 m2)-1.The outcome was all-cause and cardiocerebral vascular mortality.Results (1) A total of 562 patients were included.The median eGFR at initiation of dialysis was 5.60 (2.26-12.62) ml·min-1·(1.73 m2)-1.The median follow-up time was 17 (0-58) months from initiation of dialysis and 141 patients died within this period.The median survival time was 45.48 (43.05-47.90) months.With eGFR declined,Scr,BUN,serum uric acid,serum prealbumin,phosphorus,calcium and phosphate product,iPTH,mean arterial pressure (MAP) at initiation of dialysis increased (P＜0.05),and hemoglobin,proportion of male,proportion of diabetes comorbidity,proportion of the Charlson comorbidity index ≥5 decreased (P＜0.05).Though there was no significant difference among the four groups,the proportion of left ventricular hypertrophy comorbidity increased when eGFR declined.(2) There was no significant difference of all-cause mortality among four groups using Kaplan-Meire survival curve.Cox regression model indicated no significant difference of all-cause mortality in levels of eGFR (HR=1.012,95％CI 0.961-1.065,P=0.654).Without patients died in the first 3 months,the multivariate Cox regression model indicated eGFR at initiation of dialysis was the protective factor to 1 year survival (HR=0.791,95％CI 0.669-0.935,P＜0.01).(3) The multivariate Cox regression model indicated the risk of overall and 1 year cardiocerebral vascular death decreased with eGFR at initiation of dialysis increased (HR=0.868,95％CI 0.777-0.971,P＜0.05; HR=0.937,95％CI 0.851-0.992,P＜0.05,respectively).(4) The multivariate Cox regression model indicated eGFR at initiation of dialysis was benefit to survival of patients treated by peritoneal dialysis,with all-cause death risk decreased by 10％ when eGFR increased by 1 ml·min-1·(1.73 m2)-1 (HR=0.90,95％CI 0.81-0.99,P＜0.05).In hemodialysis patients,Kaplan-Meire survival curve was significantly different among the four groups (Log-rank test,P=0.047); the survival of the group of 8 to ＜10.5 ml·min-1·(1.73 m2)-1 was lower as compared to the groups of 6 to ＜8 (Log-rank test,P=0.033) and ＜6 ml·min-1(1.73 m2)-1 (Log-rank test,P=0.005); but the multivariate Cox regression model indicated no relationship between survival and eGFR.In the subgroup of chronic glomerulonephritis as primary renal disease,the eGFR at initiation of dialysis was the benefit factor,with all-cause death risk decreased by 16.6％ (HR=0.834,95％CI 0.736-0.946,P＜0.01) and cardiocerebral vascular death risk decreased by 18.2％ (HR=0.818,95％CI 0.669-0.999,P＜0.05) when eGFR increased by 1 ml ·min-1 ·(1.73 m2)-1.In the subgroup of chronic glomerulonephritis treated by peritoneal dialysis,the all-cause death risk decreased by 32.1％ with eGFR increased by 1 ml·min 1·(1.73 m2)-1 (HR=0.679,95％CI 0.535-0.862,P＜0.01).Conclusions Early initiation of dialysis may not be associated with improved overall survival,but may reduce cardiocerebral vascular and 1 year all-cause mortality,improve the survival of chronic glomerulonephritis patients and peritoneal dialysis patients.
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