中国血液净化

中国血液净化 ›› 2016, Vol. 15 ›› Issue (06): 357-361.doi: 10.3969/j.issn.1671-4091.2016.06.011

• 临床研究 • 上一篇    下一篇

患者水平及透析机构水平的血红蛋白变异性对血液透析患者死亡风险的影响

赵新菊1王芳,左力,王梅   

  1. 北京大学第一医院肾内科
  • 收稿日期:2015-12-30 修回日期:2016-03-31 出版日期:2016-06-12 发布日期:2016-06-19
  • 通讯作者: 左力 zuoli@bjmu.edu.cn E-mail:zuoli@bjmu.edu.cn
  • 基金资助:

    卫生公益性行业科研专项；项目名称：优化尿毒症患者管理模式的研究；批号：201502010

Effect of hemoglobin variability at patient-level and facility-level on mortality in maintenance hemodialysis patients

  • Received:2015-12-30 Revised:2016-03-31 Online:2016-06-12 Published:2016-06-19

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摘要： 目的血液透析(hemodialysis，HD)患者中患者水平的血红蛋白(hemoglobin，Hb)变异性(variability，Var)对死亡风险的影响，目前研究结果并不一致。临床实践模式对患者的贫血管理产生影响，同时影响患者水平Hb-Var 及整体透析机构水平(facility-leve，FL)Hb-Var(FL Hb-Var)。本研究旨在明确患者水平Hb-Var 及FL Hb-Var 与透析患者死亡风险间的关系。方法本回顾性队列研究使用北京市血液净化质量控制和改进中心数据登记系统的数据进行分析。研究纳入数据库中2010 年1 月1 日前稳定血液透析3 个月的患者，患者在基线期(2010 年1 月至6 月)存活，且测量3 次以上Hb 水平。患者随访至2011 年12 月31 日。至少10 名患者符合入组条件的透析室进入本研究。选取入选患者的性别，年龄，透析龄，终末期肾脏病（end stage renal disease,ESRD)病因，删失时间及原因，是否发生死亡，死亡时间，以及基线期间3 次Hb 结果。主要终点为全因死亡率。按FL Hb-Var 水平将患者分为3 组，进行对比分析。建立2 种Cox 回归模型分析患者水平Hb-Var 及FL Hb-Var 与死亡风险间的关系，并分析可能的影响因素。结果研究包括91 个透析机构共2013 例患者。随访中276 例患者死亡，66 例患者删失。患者水平Hb-Var 最高组(即＞8.8 g/L)与最低组(＜4.4 g/L)相比HR 为1.475，(95% CI1.105～1.968，P=0.008)。与年龄＜40 岁患者相比，年龄＞65 岁的患者HR 为6.764(95% CI 2.983～15.339，P＜0.001)。与女性患者相比，男性全因死亡风险HR 为1.280(95% CI 1.007～1.627，P=0.044)。ESRD 病因为糖尿病(HR=1.000)及高血压(HR 为=0.700，95% CI 0.458～1.070，P=0.100)的患者预后较差，原发病为慢性肾小球肾炎患者预后较好(HR 为=0.521，95% CI 0.458～1.070，P=0.004)。FL Hb-Var 最高组与最低组相比，死亡风险增加42.2%(HR=1.422，95% CI 1.056～1.914，P=0.020)。结论HD 患者水平Hb-Var 适度波动不影响死亡率，但波动过大(患者水平Hb-Var＞8.8g/L)则死亡风险明显增加。年龄＞65岁、男性、ESRD 原发病为糖尿病及高血压的患者死亡风险增加。FL Hb-Var 显著增高的透析机构，其机构内患者的死亡风险增加。改善透析机构的贫血管理实践模式有助于降低患者死亡风险。

关键词: 血红蛋白变异性, 血液透析, 死亡

Abstract: Objective Results describing the relationship between hemoglobin variability (Hb-Var) of patient-level and mortality were ambiguous in hemodialysis (HD) patients. However, clinical anemia management pattern has important effects on patients’hemoglobin condition as well as on Hb-Var of patient- level
(PL Hb-Var) and Hb-Var of facility-level (FL Hb-Var). This study aimed to analyze the effect of PL Hb-Var and FL Hb-Var on mortality in HD patients. Methods This retrospective cohort analysis used the data in Beijing Hemodialysis Quality Control and Improvement Center (BJHDQCIC) database. Patients on stable HD
(＞3 month) before Jan. 1st, 2010 in this database were included. Patients should survive the baseline phase (Jan.-Jun., 2010) and had at least 3 Hb measurements during the baseline phase. Study subjects were followed up until Dec. 31st, 2011. Dialysis facilities with 10 or more eligible patients were included in this study. For every patient, demographics, primary cause of end stage renal disease, date of first HD, date of censoring and reason for censoring, date of death, cause of death, and 3 Hb measurements were extracted. The primary outcome was all-cause mortality. Patients were divided into 3 groups according to the FL Hb-Var. Two Cox regression models were established to analyze the relationship between mortality and PL Hb-Var and FL Hb-Var. The possible effective factors were also analyzed. Results This study included 2,013 subjects from 91 facilities. There were 276 death and 66 patients censored during follow-up period. Compared with the lowest PL Hb-Var group (＜4.4 g/L), mortality in the highest PL Hb-Var group (＞8.8 g/L) increased by 47.5% (HR=
1.475, 95% CI 1.105～1.968, P=0.008). Compared with the patients ＜40 years old, the crude hazard ratio of death for patients＞65 years old was 6.764 (95% CI 2.983～15.339, P＜0.001). The hazard ratio of death for males was 1.280 (95% CI 1.007～1.627, P=0.044). Outcomes for patients with diabetes (HR=1.000) and hypertension (HR=0.700, 95% CI 0.458～1.070, P=0.100) as the primary ESRD causes were relatively worse. While outcome for patients with glomerulonephritis was better (HR=0.521, 0.458～1.070, P=0.004). After adjustments, the mortality risk increased by 42.2% in the highest FL Hb-Var group compared with the lowest group (HR=1.422, 95% CI 1.056～1.914, P=0.020). Conclusions Moderate fluctuation of PL Hb-Var did not affect mortality. However, greater fluctuation (＞8.8g/L) increased death risk. Patients with age ＞65 years old, male gender, and diabetes and hypertension as the primary ESRD causes had higher mortality risk. Patients in facilities in the highest FL Hb-Var group had higher mortality risk. Effort aiming to improve anemia management pattern in facilities will reduce the mortality.

Key words: hemoglobin variability, hemodialysis, mortality