腹膜透析患者起始透析剂量对生存率的影响

Effect of initial dialysis dose on survival in peritoneal dialysis patients

目的比较不同透析时机开始腹膜透析(peritoneal dialysis,PD)的患者,每日8 L及6 L剂量起始对生存率的影响。方法回顾性研究2012年1月至2019年12月单中心规律随访,透析超过3个月的患者,根据开始透析时不同的估算肾小球滤过率(estimated glomerular filtration rate,eGFR)分为3组,A组eGFR<4 mL·(min·1.73 m^(2))^(-1),B组eGFR≥4,<6 mL·(min·1.73 m^(2))^(-1),C组eGFR≥6 mL·(min·1.73 m^(2))^(-1),调查原发病、透析初始月白蛋白、转运功能及最终转归,比较不同组PD患者在使用6 L和8 L起始透析剂量的生存率差异。结果共研究504例患者,A组52例,B组156例,C组296例,三组患者5年生存率分别为64.0%、79.0%、71.6%,差异无统计学意义(P=0.306),Kaplan-Meier生存曲线分析,根据eGFR分层后,A组和B组使用每日6 L起始的PD患者的中位生存时间低于每日8 L起始的患者[(48.78±7.18)个月比(95.46±7.18)个月,χ^(2)=5.439,P=0.020,(79.78±5.87)个月比(99.66±4.09)个月,χ^(2)=4.509,P=0.034],而C组患者,6 L及8 L起始比较对生存没有明显差异(χ^(2)=0.388,P=0.533)。每日8 L起始的患者,不同透析时机患者的生存时间差异无统计学意义(χ^(2)=0.280 P=0.870)。多因素Cox生存分析示,糖尿病、透析前低蛋白血症、老年是导致患者死亡的独立危险因素,起始为每日8 L透析剂量是生存的保护性因素(OR=0.577,95%CI 0.336~0.990,P=0.037),腹膜转运功能和透析前eGFR不影响PD患者的生存率。结论(1)对于透析开始时残余肾功能较差的患者,起始透析剂量不足是影响PD患者生存率的独立危险因素。(2)对于开始透析时eGFR≥6 mL·(min·1.73 m^(2))^(-1)的患者,每日8 L起始的透析剂量并不能比6 L带来更大的生存获益。

Objective To compare the effect of initial daily dialysis dose of 8 L versus 6 L on the survival rate in peritoneal dialysis(PD)patients with different baseline residual renal function.Methods From January 2012 to December 2019,504 PD patients treated over 3 months were enrolled retrospectively.According to the baseline value of estimated glomerular filtration rate(eGFR),they were divided into three groups.That was eGFR<4 mL·(min·1.73m^(2))^(-1)in group A(n=52),4-6 mL·(min·1.73m^(2))^(-1)in group B(n=156)and≥6 mL·(min·1.73m^(2))^(-1)in group C(n=296).Primary etiologies,laboratory parameters at Month 1 post-PD,peritoneal transport functions and clinical outcomes were recorded.The survival rate of different initial daily dialysis doses(6 L versus 8 L)was compared among 3 groups.Results The 5-year survival rates of three groups were 64.0%,79.0%and 71.6%respectively.And there was no statistical difference(P=0.306).Kaplan-Meier analysis indicated that,except for group C,median survival time of PD patients with 6 L initial dialysis dose was lower than that with 8 L in group A/B(48.78±7.18 versus 95.46±7.18 months,χ^(2)=5.439 P=0.020,79.78±5.87 versus 99.66±4.09 months,χ^(2)=4.509,P=0.034).No significant difference existed in survival time of patients with 8 L/d with different timing of dialysis(χ^(2)=0.280,P=0.870).Multivariate Cox regression analysis revealed that diabetes mellitus,baseline hypoalbuminemia and advanced age were independent risk factors for patient mortality.The initial daily dialysis dose of 8 L was a protective factor(OR=0.577,95%CI 0.336-0.990,P=0.037).Peritoneal transport function and baseline eGFR had no effect upon the prognosis of PD patients.Conclusions For PD patients with poor residual renal function at the initiation of PD,low dialysis dose independently predicts patient mortality.And 8L initial daily dialysis dose yields no greater survival benefits than 6 L/d in those with eGFR≥6 mL·(min·1.73m^(2))^(-1) at the initiation of dialysis.