摘要
目的 进一步探讨透析前慢性肾脏病(chronic kidney disease,CKD)管理是否在血液透析后具有"长期效应",为更好的推动CKD管理从经济学以及人口学角度贡献力量.方法 纳入2015年3月一2018年3月在江苏大学附属医院CKD管理门诊随诊并进入透析的70例患者(管理组),及同时期从肾脏内科专科门诊进入透析的142例患者(非管理组),随访5年,比较2组患者透析启动时以及透析后1年内的住院情况及费用,以及透析后1年、5年的死亡情况,并分析各种因素对患者全因死亡的影响.结果 启动透析时管理组人均总住院费用少于非管理组(t=-3.100,P=0.002).透析后1年内管理组的人均总住院费用少于非管理(t=-2.269,P=0.024),主要归因于药品、检验、治疗、手术及输血费用的减少.在透析启动时以及透析开始后1年内,多元线性回归发现不管是未调整、根据年龄和性别进行调整、根据合并症进行调整、根据进入血液透析时的基线实验室指标进行调整还是根据启动血液透析时的血管通路情况进行调整,CKD管理与住院人均总费用的降低独立相关(透析启动时β=0.386、0.392、0.392、0.359、0.248,P分别＜0.001、＜0.001、＜0.001、＜0.001、0.018;透析1年内β=0.151、0.154、0.148、0.168、0.343,P=0.028、0.025、0.038、0.021、0.002).Kaplan-Meier分析显示管理组透析5年的累积生存率差异有统计学意义(χ2=3.947,P=0.047).多因素分析结果显示年龄(HR=1.042,95%CI:1.021～1.062,P＜0.001)和合并糖尿病(HR=0.390,95%CI:0.226～0.671,P=0.001)是患者全因死亡的独立危险因素,而透析前CKD管理则是患者全因死亡的保护性因素(HR=0.503,95%CI:0.295～0.857,P=0.012).结论 透析前CKD管理对透析后经济结果有遗留影响,能改善维持性血液透析患者的长期预后,在管理工作中尤其要关注糖尿病及老年患者.
Abstract
Objective To further explore whether the management of chronic kidney disease(CKD)be-fore dialysis has a long-term effect in the period after hemodialysis,so as to contribute to the better promotion of CKD management from the perspective of economics and demography.Methods This study enrolled 70 patients with initial hemodialysis from the CKD Outpatient Clinic(management group,group M)and 142 pa-tients with initial hemodialysis from the Nephrology Clinic(non-management group,group NM)in the Affili-ated Hospital of Jiangsu University in the period from March 2015 to March 2018.The patients were followed up for 5 years,and the hospitalization and expenses at the initial of dialysis and within 1 year after dialysis,as well as the death at 1 year and 5 years after dialysis were compared between the two groups,and the influence of various factors on all-cause death was analyzed.Results When starting dialysis,the total hospitalization cost per capita in group NM was significantly higher than that in the group M(t=-3.100,P=0.002).The total hospitalization cost per capita in group M was significantly lower than that in the group NM within 1 year af-ter dialysis(t=-2.269,P=0.024),this is mainly due to a decrease in the cost of medicines,tests,treatments,sur-geries and blood transfusions.Multiple linear regression found that CKD management was independently as-sociated with a reduction in total inpatient costs per patient,whether unadjusted,adjusted for age and sex,ad-justed for comorbidities,adjusted for baseline laboratory measures at hemodialysis starting,or adjusted for vascular access at hemodialysis initiation,at the time of initiation of dialysis and within one year after initia-tion of dialysis(Dialysis start-up β=0.386,0.392,0.392,0.359,0.248,P＜0.001,＜0.001,＜0.001,＜0.001,=0.018,respectively;Within 1 year of dialysis β=0.151,0.154,0.148,0.168,0.343,P=0.028,0.025,0.038,0.021,0.002,respectively).Kaplan-Meier analysis showed that the 5-year cumulative survival rate difference was statistically significant(χ2=3.947,P=0.047).The results of multivariate analysis showed that age and dia-betes mellitus were independent risk factors for all-cause death(HR=1.042,0.390,95% CI:1.021～1.062,0.226～0.671,P＜0.001,0.001),while pre-dialysis CKD management was protective factor for all-cause death(HR=0.503,95% CI:0.295～0.857,P=0.012).Conclusions Pre-dialysis CKD management has a lega-cy effect on post-dialysis economic outcomes and can improve the long-term prognosis of maintenance hemo-dialysis patients,we should pay more attention to diabetes and elderly patients in CKD management.
基金项目
镇江市科技创新(重点研发计划-社会发展)项目(SH2022036)
上海市"科技创新行动计划"长三角科技创新共同体领域项目(21002411500)
NETL
NSTL
万方数据