延长透析时间无法改善生活质量


  【24drs.com】新研究显示,延长每周血液透析的总时间,并不会影响生活质量,但是对血压等其它参数有正面影响。
  
  观察型研究认为每周延长透析时间可以改善生活质量、存活、与各种临床和检验参数,多伦多大学健康网络的Christopher Chan医师表示,不过,这个议题的随机控制试验资料很少,对于可能的伤害仍是有所争议的;他在美国肾脏协会第35届透析年会发表其研究团队的随机控制试验结果。
  
  这篇多国试验在澳大利亚、加拿大、中国和新西兰等国的40个地点进行,延长时间组的100名病患中,血液透析目标是每周至少24小时、为期12个月;标准组的100名病患中,目标是每周10-15小时。
  
  研究对象每周须进行3次透析,频率上没有其它限制,每次洗肾时间或地点也没有限制。
  
  使用「欧洲生活质量五面矢量表(EuroQOL five-dimensions questionnaire,EQ-5D)」问卷评估主要结果—从开始时到12个月时的生活质量变化,每3个月由不知情的采访者进行。
  
  次级结果包括:存活、心血管事件、其它生活质量测量、生物和血液替代品的改变、安全性与血管通路,以及显示EQ-5D确认的好处之后的成本效果分析。
  
  开始时,研究对象平均年龄52岁,每周平均透析13.9小时,两组的男性都多于女性。
  
  12个月时,延长时间组平均每周透析22.1小时,标准组平均每周14.2小时,延长时间组对于目标时间的遵守度低于标准组(74.2% vs 94.5%)。
  Chan医师解释,遵守度的结果不令人意外,让人遵守延长时间一定有难度。
  
  延长时间组与标准组的生活质量测量跟开始时相比都没有差异,Chan医师报告指出,值得注意的是,两组在开始时的生活质量分数0.76是相当高的,高于透析人口的预期。
  
  会议主持人、维吉尼亚州Lynchburg的肾脏内科医师Robert Lockridge表示,他从这篇研究得到的关键是,就血液透析而言,时间与频率造成差异;不过,令他惊讶的是,两组之间没有差异。
  
  他表示,有足够的文献显示,支持「更加频繁和更长的血液透析更好」的概念;这个议题在美国是个专门知识。
  
  两组在12个月时的收缩压没有差异,不过延长时间组病患的降血压药数量有减少。
  
  相较于标准组,延长时间组的病患也有比较高的血色素、比较低的钾和磷,红血球生成刺激剂的需要量也比较低。
  
  两组在12个月时的EQ-5D心智分数没有差异。
  
  Chan医师报告指出,生理方面的分数偏好延长透析,但是这些是次要结果。
  
  延长时间组的死亡人数比标准组多(5 vs 2),但是两组的心血管以及血管通路事件是类似的 ,两组都没有发生严重的不良反应事件。
  
  根据这些资料,Chan医师等人结论指出,延长血液透析时间与生活质量测量没有关联;不过,他们指出,对于其它检验参数的影响是正面的。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=7158&x_classno=0
  

Extending Dialysis Hours Fails to Improve Quality of Life

By Meg Barbor
Medscape Medical News

NEW ORLEANS — Increasing the hours of hemodialysis each week does not affect quality of life, but it does have a positive influence on other parameters, including blood pressure, new research has shown.

Observational studies have suggested that extending the weekly hours of dialysis improves quality of life, survival, and a variety of clinical and laboratory parameters. "However, few randomized controlled data exist on the topic, and there is still some debate" about possible harms, said Christopher Chan, MD, from the University Health Network in Toronto.

He presented results from his team's randomized controlled trial here at the American Society of Nephrology 35th Annual Dialysis Conference.

The multinational trial was conducted at 40 sites in Australia, Canada, China, and New Zealand. For the 100 patients in the extended group, the hemodialysis target was at least 24 hours each week for 12 months; for the 100 patients in the standard group, the target was 10 to 15 hours each week.

Participants were required to undergo three dialysis sessions every week, but there were no other restrictions on frequency, and there were no restrictions on the duration or location of the sessions.

The primary outcome — change in quality-of-life measures from baseline to 12 months — was evaluated with the EuroQOL five-dimensions questionnaire (EQ-5D), which was administered by a blinded interviewer every 3 months.

Secondary outcomes included survival, cardiovascular events, other quality-of-life measures, change in biologic and hematologic surrogates, safety and vascular access, and cost–utility after the demonstration of EQ-5D-determined benefit.

At baseline, mean age of the participants was 52 years and mean duration of weekly dialysis was 13.9 hours. There were more men than women in both the extended and standard groups.

At 12 months, mean duration of weekly dialysis was 22.1 hours in the extended group and 14.2 hours in the standard group. Adherence to the target hours was worse in the extended group than in the standard group (74.2% vs 94.5%)

"The adherence pattern isn't that surprising," Dr Chan explained. "It has always been difficult to get people to adhere to extended hours."

Surprise Finding

There was no difference in the change in quality-of-life measures from baseline between the extended and standard groups. "However, it is notable that the baseline QOL score of 0.76 was quite high in both groups, and higher than expected in the dialysis population," Dr Chan reported.

"The key thing I learned from this study is that in terms of hemodialysis, time and frequency make a difference," said session moderator Robert Lockridge, MD, from Lynchburg Nephrology Physicians in Virginia.

However, he added, "it is surprising to me that there was no difference between the two groups."

"There's enough literature out there to support the notion that more frequent and longer hemodialysis is better; the issue in the United States is know-how," he told Medscape Medical News.

There was no difference in systolic blood pressure at 12 months between the two groups, although there was a decrease in the number of blood-pressure-lowering agents patients in the extended group were receiving.

Patients in the extended group also had higher levels of hemoglobin and lower levels of potassium and phosphate than those in the standard group, and required lower doses of erythropoiesis-stimulating agents.

There was no significant difference between groups in the EQ-5D mental score at 12 months.

"The difference in physical score favored extended dialysis," Dr Chan reported, "but this is a secondary outcome."

There were more deaths in the extended group than in the standard group (5 vs 2), but cardiovascular events were similar in the two groups, as was vascular access. No significant serious adverse events occurred in either group.

On the basis of these data, Dr Chan and his colleagues conclude that there is no correlation between extended hemodialysis hours and quality-of-life measures; however, they note, the impact on several other laboratory parameters is positive.

Dr Chan reports financial relationships with Baxter International and Intelomed. Dr Lockridge has disclosed no relevant financial relationships.

American Society of Nephrology 35th Annual Dialysis Conference: Abstract HI-OR08. Presented January 31, 2015.

    
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