透析初期贫血状态与维持性血液透析患者预后的相关关系

Relationship between early dialysis anemia status and prognosis in maintenance hemodialysis patients

目的分析成人维持性血液透析(maintenance hemodialysis,MHD)患者透析初期贫血状态,探究透析初期贫血状态与MHD患者早期及长期生存率的关系。方法该研究为回顾性队列研究。回顾性收集浙江省透析质量控制中心登记系统中2013年1月1日至2020年12月31日新进入MHD患者的基线人口学和临床资料,根据患者透析初期血红蛋白水平将其分为高血红蛋白组(血红蛋白≥110 g/L)、中血红蛋白组(80 g/L≤血红蛋白<110 g/L)及低血红蛋白组(血红蛋白<80 g/L),比较3组患者基线资料的差异,分析8年间MHD患者血红蛋白的变化趋势。随访终点为患者转腹膜透析、肾移植、死亡或截至2021年12月31日。早期死亡定义为MHD患者开始接受透析治疗后6个月内发生的全因死亡事件,长期死亡定义为透析6个月以上发生的全因死亡事件。Kaplan-Meier生存曲线和Log-rank检验分析患者的生存率并比较3组患者生存率的差异。采用多因素Cox回归模型分析透析初期贫血(血红蛋白<110 g/L)与MHD患者早期死亡及长期死亡风险的关系。结果该研究纳入MHD患者36216例,年龄(61.3±15.5)岁,男性22163例(61.20%),透析初期血红蛋白为(89.33±20.89)g/L,血红蛋白(≥110 g/L)达标5952例(16.43%)。低血红蛋白组12232例(33.78%),中血红蛋白组18032例(49.79%),高血红蛋白组5952例(16.43%)。3组间性别分布、年龄、慢性肾小球肾炎比例、糖尿病肾病比例、糖尿病比例、心脑血管疾病比例、肿瘤比例、临时导管比例、长期导管比例、自体动静脉内瘘比例、血肌酐、血磷、血钙、C反应蛋白、全段甲状旁腺素、血白细胞、血小板、血清白蛋白、三酰甘油和总胆固醇的差异均有统计学意义(均P<0.05)。8年间MHD患者血红蛋白水平呈逐年升高趋势,依次为(88.48±22.07)g/L、(88.52±21.43)g/L、(87.86±21.29)g/L、(88.93±20.69)g/L、(88.87±20.69)g/L、(90.03±20.47)g/L、(90.74±20.31)g/L和(90.31±20.54)g/L。MHD患者发生早期死亡2176例(6.01%),发生长期死亡6557例(18.10%)。Kaplan-Meier生存曲线分析结果显示,低血红蛋白组早期生存率显著低于高血红蛋白组(Log-rank检验,χ^(2)=57.115,P<0.001)和中血红蛋白组(Log-rank检验,χ^(2)=49.918,P<0.001);低血红蛋白组(Log-rank检验,χ^(2)=107.097,P<0.001)和中血红蛋白组(Log-rank检验,χ^(2)=47.430,P<0.001)长期生存率均显著低于高血红蛋白组。多因素Cox回归分析结果显示透析初期血红蛋白<80 g/L是MHD患者早期死亡的独立影响因素(以血红蛋白≥110 g/L为参照,HR=1.307,95%CI 1.096~1.559),而透析初期80 g/L≤血红蛋白<110 g/L和血红蛋白<80 g/L(以血红蛋白≥110 g/L为参照,分别HR=1.108,95%CI 1.021~1.203;HR=1.228,95%CI 1.127~1.339)是MHD患者长期死亡的独立影响因素。结论MHD患者透析初期血红蛋白达标率较低,透析初期血红蛋白<80 g/L为MHD患者早期死亡的独立危险因素,透析初期血红蛋白<110 g/L是MHD患者长期死亡的独立危险因素。

Objective To analyze the status of anemia at the beginning of dialysis in maintenance hemodialysis(MHD)adult patients,and to explore the relationship between early dialysis anemia and early survival and long-term survival.Methods It was a retrospective cohort study.The baseline demographic and clinical data of newly admitted MHD patients from January 1,2013 to December 31,2020 were retrospectively analyzed.According to the hemoglobin(Hb)level at the beginning of dialysis,the patients were divided into high Hb group(Hb≥110 g/L),middle Hb group(80 g/L≤Hb<110 g/L)and low Hb group(Hb<80 g/L).The baseline data among the three groups were compared,and the changing trend of Hb level in MHD patients during the 8 years was analyzed.The follow-up ended at peritoneal dialysis,kidney transplantation,death or on December 31,2021.All-cause death event within 6 months after the initiation of dialysis was defined as early death,while all-cause death event more than 6 months after the initiation of dialysis was defined as long-term death.Kaplan-Meier survival curve was used to analyze the survival rate,and log-rank test was used to compare the survival rates among the three groups.Multivariate Cox regression analysis model was used to analyze the association between anemia(Hb<110 g/L)at the beginning of dialysis and both early and long-term mortality.Results A total of 36216 MHD patients were included in this study,with age of(61.3±15.5)years old and 22163 males(61.20%).The Hb at the beginning of dialysis was(89.33±20.89)g/L.The compliance rate of Hb(≥110 g/L)was 16.43%(5952/36216).There were 12232 patients(33.78%),18032 patients(49.79%),and 5952 patients(16.43%)in low Hb group,middle Hb group,and high Hb group,respectively.There were statistically significant differences in gender distribution,age,serum creatinine,blood phosphorus,blood calcium,C-reactive protein,intact parathyroid hormone,blood leukocytes,platelets,serum albumin,triglyceride,total cholesterol,and proportions of chronic glomerulonephritis,diabetic nephropathy,diabetes mellitus,cardiovascular and cerebrovascular diseases,tumors,emporary catheter,long-term catheter and autologous arteriovenous fistula among the three groups(all P<0.05).During the 8-year period,the Hb level had an increased trend steadily each year,and Hb was(88.48±22.07)g/L,(88.52±21.43)g/L,(87.86±21.29)g/L,(88.93±20.69)g/L,(88.87±20.69)g/L,(90.03±20.47)g/L,(90.74±20.31)g/L and(90.31±20.54)g/L year by year.There were 2176 early deaths(6.01%),and 6557 long-term deaths(18.10%)by the end of follow-up.Kaplan-Meier survival curve showed that early survival rate of low Hb group was significantly lower than those of high Hb group(log-rank test,χ^(2)=57.115,P<0.001)and middle Hb group(log-rank test,χ^(2)=49.918,P<0.001),and long-term survival rates of low Hb group(log-rank test,χ^(2)=107.097,P<0.001)and middle Hb group(log-rank test,χ^(2)=47.430,P<0.001)were significantly lower than that of high Hb group.Multivariate Cox regression analysis showed that Hb<80 g/L at the beginning of dialysis was an independent influencing factor of early death(Hb≥110 g/L as a reference,HR=1.307,95%CI 1.096-1.559),and 80 g/L≤Hb<110 g/L and Hb<80 g/L at the beginning of dialysis were the independent influencing factors of long-term death(Hb≥110 g/L as a reference,HR=1.108,95%CI 1.021-1.203;HR=1.228,95%CI 1.127-1.339,respectively)in MHD patients.Conclusions The compliance rate of Hb at the beginning of dialysis in MHD patients is low.Hb<80 g/L at the beginning of dialysis is an independent risk factor of early death,and Hb<110 g/L at the beginning of dialysis is an independent risk factor of long-term death in MHD patients.