Tasa de filtrado glomerular inicial y supervivencia en hemodiálisis. El papel del acceso vascular permanente

Marinovich, Sergio; Pérez-Loredo, Jaime; Lavorato, Carlos; Rosa-Díez, Guillermo; Bisigniano, Liliana; Fernández, Víctor; Hansen-Krogh, Daniela

doi:10.3265/Nefrologia.pre2013.Oct.11957

Article information

Antecedentes: Entre 2004 y 2009, se observó en Argentina un aumento significativo del número de pacientes que iniciaban un tratamiento crónico de hemodiálisis (HD) con una tasa de filtrado glomerular estimada (TFGe) ≥ 10 ml/min/1,73 m2. Métodos: Para su estudio, calculamos las razones de riesgo (RR) de mortalidad en una cohorte de individuos incidentes en HD del Registro Argentino de Diálisis Crónica (2004-2009), que se agrupó, en función de la TFG inicial estimada por CKD-EPI (0-4,9; 5-9,9; 10-14,9; y ≥ 15 ml/min/1,73 m2, siendo 0-4,9 el grupo de referencia), en tres cohortes: «población total», «cohorte sana» (< 65 años sin diabetes ni ningún tipo de comorbilidad) y «cohorte con entrada prevista» (con acceso vascular permanente). Resultados: Tras ajustar los datos de la población (n = 16 931) en función de la edad, el sexo, las enfermedades coexistentes, la albúmina sérica, los ingresos y la existencia de un acceso vascular temporal, se observó una RR de 1,19 (95 % IC: 1,07-1,33) en el grupo con una TFGe ≥ 15 ml/min/1,73 m2. En la cohorte formada por 3897 individuos «sanos», se obtuvieron, tras ajustar las mismas covariables, unas RR de 1,44 (95 % IC: 1,08-1,65) y 1,65 (95 % IC: 1,06-2,55) para los grupos con TFGe iniciales de 10-14,9 y ≥ 15 ml/min/1,73 m2, respectivamente. En los pacientes con «entrada prevista» (n = 6280), tras ajustar los resultados en función de la edad, el sexo, la comorbilidad, el nivel de albúmina sérica y los ingresos, las RR de todos los grupos no difirieron significativamente de las del grupo de control. Conclusiones: Iniciar el tratamiento de HD con una TFGe > 10 ml/min/1,73 m2 no revela ninguna ventaja de supervivencia. La mayor mortalidad del grupo con mayor TFGe que inicia la diálisis es un «artefacto» que está relacionado con una mayor edad, la existencia de más comorbilidades, la hipoalbuminemia y el uso de accesos vasculares temporales.

Palabras clave:

Acceso vascular

Palabras clave:

Sobrevida

Palabras clave:

Hemodiálisis

Palabras clave:

Tasa de filtración glomerular

Palabras clave:

Enfermedad renal crónica terminal

Palabras clave:

Epidemiología

Background: A significant increase in the number of patients starting chronic hemodialysis (HD) with an estimated glomerular filtration rate (eGFR)≥10mL/min/1.73m2 was observed in Argentina between 2004 and 2009. Methods: In order to study this topic, we calculated the mortality hazard ratios (HR) in a cohort of incident HD individuals from the Argentine Registry of Chronic Dialysis [Registro Argentino de Diálisis Crónica] (2004-2009), grouped according to the initial eGFR (0-4.9, 5-9.9, 10-14.9 and ≥15mL/min/1.73m2 ; reference group 0-4.9) estimated by CKD-EPI; in three cohorts: “total population”, “healthy (<65 years, without diabetes or comorbidities) and “planned entry” (with permanent vascular access). Results: After adjusting the population (n=16,931) for age, gender, coexisting conditions, serum albumin, income, and temporary vascular access a HR of 1.19 (95%CI:1.07-1.33) was observed in the group with eGFR≥15mL/min/1.73m2. In the cohort of 3,897 “healthy” after adjusting for the same co-variates, HRs of 1.44 (95%CI: 1.08-1.65) and 1.65 (95%CI: 1.06-2.55) were obtained for the groups with baseline eGFR values of 10-14.9 and ≥15mL/min/1.73m2, respectively. In “planned entry” patients (n=6,280), after adjusting for age, gender, co-morbidities, serum albumin and income, HRs in all groups were not significantly different as compared to the control group. Conclusions: HD initiation with eGFR>10mL/min/1.73m2 shows no survival advantage. The higher mortality in the group with >eGFR starting dialysis looks like an “artifact” related to higher age, more co-morbidities, low albuminemia and the use of temporary vascular access.

Keywords:

Vascular access

Keywords:

Survival

Keywords:

Hemodialysis

Keywords:

Glomerular filtration rate

Keywords:

End-stage renal diseases

Keywords:

Clinical epidemiology

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Bibliografía

[1]

NKF-DOQI clinical practice guidelines for hemodialysis adequacy. National Kidney Foundation. Am J Kidney Dis 1997;30(3 Suppl 2):S15-66.

[2]

Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006;48 Suppl 1:S2-90. [Pubmed]

[3]

Rosansky S, Glassock RJ, Clark WF. Early start of dialysis: a critical review. Clin J Am Soc Nephrol 2011;6:1222-8. [Pubmed]

[4]

Bonomini V, Feletti C, Scolari MP, Stefoni S. Benefits of early initiation of dialysis. Kidney Int Suppl 1985;17:S57-9. [Pubmed]

[5]

Keshaviah PR, Emerson PF, Nolph KD. Timely initiation of dialysis: a urea kinetic approach. Am J Kidney Dis 1999;33:344-8. [Pubmed]

[6]

Hakim RM, Lazarus JM. Initiation of dialysis. J Am Soc Nephrol 1995;6(5):1319-28. [Pubmed]

[7]

Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 1996;7(2):198-207.

[8]

Tattersall J, Greenwood R, Farrington K. Urea kinetics and when to commence dialysis. Am J Nephrol 1995;15:283-9. [Pubmed]

[9]

Obrador GT, Arora P, Kausz AT, Ruthazer R, Pereira BJ, Levey AS. Level of renal function at the initiation of dialysis in the U.S. end stage renal disease population. Kidney Int 1999;56:2227-35. [Pubmed]

[10]

Tattersall JE, Pedrini L, Martin-Malo AM. When to start dialysis. Nephrol Dial Transplant 2002;17Suppl7:10. [Pubmed]

[11]

Korevaar JC, Jansen MA, Dekker FW, Jager KJ, Boeschoten EW, Krediet RT, et al. When to initiate dialysis: effect of proposed US guidelines on survival. Lancet 2001;358:1046-50. [Pubmed]

[12]

U.S. Department of Health & Human Services Form Approved Centers for Medicare & Medicaid Services. 2728. CMS 2728. Chronic Renal Disease Medical Evidence Report. 18e point, ¿NOTE¿. 1997.

[13]

Russ GR. ANZDATA Registry Report 2000. Adelaide: Australian and New Zealand Dialysis and Transplant Registry. 2000. Available at: www.anzdata.org.au/v1/annual_reports_download.html [accessed November 11, 2012].

[14]

Churchill DN, Blake PG, Jindal KK, Toffelmire EB, Goldstein MB. Clinical practice guidelines for initiation of dialysis. Canadian Society of Nephrology. J Am Soc Nephrol 1999;10 Suppl 13:S289-91.

[15]

The CARI Guidelines: Caring for Australians with Renal Impairment. Available at: http://www.cari.org.au/dialysis_accept_published.php [accessed November 11, 2012].

[16]

Kelly J, Stanley M, Harris D. The CARI guidelines: acceptance into dialysis guidelines. Nephrology (Carlton) 2005;10 Suppl 4:S46-60.

[17]

17 Traynor JP, Simpson K, Geddes CC, Deighan CJ, Fox JG. Early initiation of dialysis fails to prolong survival in patients with end stage renal failure. J Am Soc Nephrol 2002;13:2125-32. [Pubmed]

[18]

Lassalle M, Labeeuw M, Frimat L, Villar E, Joyeux V, Couchoud C, et al. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int 2010;77:700-7. [Pubmed]

[19]

Rosansky SJ, Clark WF, Eggers P, Glassock RJ. Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful? Kidney Int 2009;76:257-61. [Pubmed]

[20]

Stel VS, Dekker FW, Ansell D, Augustijn H, Casino FG, Collart F, et al. Residual renal function at the start of dialysis and clinical outcomes. Nephrol Dial Transplant 2009;24:3175-82. [Pubmed]

[21]

Venturelli C, Brunori G. When to start chronic dialysis: as late as possible. G Ital Nefrol 2010;27(6):568-73. [Pubmed]

[22]

Hwang SL, Yang WC, Lin MY, Mau LW, Chen HC. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant 2010;25(8):2616-24. [Pubmed]

[23]

Beddhu S, Samore MH, Roberts MS, Stoddard GJ, Ramkumar N, Pappas LM, et al. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol 2003;14:2305-12. [Pubmed]

[24]

Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, et al. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis 2005;46:887-96. [Pubmed]

[25]

Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. A randomized, controlled trial of early versus late initiation of dialysis. IDEAL Study. N Engl J Med 2010;363(7):609-19.

[26]

Marinovich S, Lavorato C, Celia E, Araujo JL, Bisignano L, Soratti M. Registro de pacientes en diálisis crónica en Argentina 2004-2005. Nefrología Argentina 2008;6(Suppl 1):9-64. Available at: http://www.nefrologiaargentina.org.ar/resultados.php?t=3&IdRevista=20 (accessed November 11, 2012).

[27]

Registro Argentino de Diálisis Crónica 2009-2010. Informe 2011. Available at: http://san.org.ar/docs/REGISTRO_ARGENTINO_DE_DIALISIS_CRONICA2009_2010.pdf [accessed November 11, 2012].

[28]

Marinovich S, Lavorato C, Celia E, Araujo JL, Bisignano L, Soratti M. Mortalidad según el registro de pacientes en Diálisis Crónica de Argentina 2004-2005. Revista de Nefrología, Diálisis y Trasplante 2009;29(2):13-28. Available at: http://www.renal.org.ar/imagenes/revistas_anteriores/revista_29_2.pdf [accessed November 11, 2012].

[29]

Marinovich S, Lavorato C, Moriñigo C, Celia E, Bisignano L, Soratti M, et al. A new pronostic index for one-year survival in incident hemodialysis patients. Int J Artif Organs 2010;33(10):689-99. [Pubmed]

[30]

Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: a development and validation. J Chronic Dis 1987;40:373-83. [Pubmed]

[31]

United States Renal Data System. Available at: http://www.usrds.org/ [accessed November 11, 2012].

[32]

Wright S, Klausner D, Baird B, Williams ME, Steinman T, Tang H, et al. Timing of dialysis initiation and survival in ESRD. Clin J Am Soc Nephrol 2010;5:1828-35.

[33]

ERA-EDTA Registry. Available at: http://www.era-edta-reg.org/index.jsp?p=1 [accessed November 11, 2012].

[34]

Société de Nephrologie. Available at: http://www.soc-nephrologie.org/ [accessed November 11, 2012].

[35]

Société de Nephrologie. Registre REIN. Available at: http://www.soc-nephrologie.org/REIN/documents.htm [accessed November 11, 2012].

[36]

Canadian Institute for Health Information. Available at: http://www.cihi.ca/ [accessed November 11, 2012].

[37]

Clark WF, Na Y, Rosansky SJ, Sontrop JM, Macnab JJ, Glassock RJ, et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ 2011;183:47-53. [Pubmed]

[38]

Bureau of National Health Insurance. Department of Health. Taiwan. Available at: http://www.nhi.gov.tw/english/ [accessed November 11, 2012].

[39]

Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC; Taiwan Society of Nephrology. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant 2010;25:2616-24. [Pubmed]

[40]

Tattersall J, Dekker F, Heimbürger O, Jager KJ, Lameire N, Lindley E, et al. When to start dialysis: updated guidance following publication of the Initiating Dialysis Early and Late (IDEAL) study. Nephrol Dial Transplant 2011;26(7):2082-6. [Pubmed]

[41]

Evans M, Tettamanti G, Nyrén O, Bellocco R, Fored CM, Elinder CG. No survival benefit from early start of dialysis in a population-based, inception cohort study of CKD-patients in Sweden. J Intern Med 2011;269:289-98. [Pubmed]

[42]

Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16(1):31-41. [Pubmed]

[43]

Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Chronic kidney disease epidemiology collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 2006;145:247-54. [Pubmed]

[44]

Foley RN, Chen SC, Collins AJ. Hemodialysis access at initiation in the United States, 2005 to 2007: still "catheter first". Hemodial Int 2009;13(4):533-42. [Pubmed]

[45]

Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150(9):604-12. [Pubmed]

[46]

Perez-Loredo J, Lavorato CA, Negri AL, Der M, Lercari J, Casaliba A. Comparación gráfica de ecuaciones de estimación del filtrado glomerular. Revista de Nefrologia, Diálisis y Trasplante 2011;31:34-43. Available at: http://www.renal.org.ar/revista_31_1.php [accessed November 11, 2012].

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