Предикторы летального исхода у больных на гемодиализе

Выявление предикторов летального исхода имеет большое значение для прогноза исхода лечения гемодиализом (ГД) и выбора оптимальной тактики коррекции этих нарушений у больных на ГД, а также профилактики их развития до начала заместительной почечной терапии. Целью настоящей работы явилось выяснение влияния на выживаемость больных ряда важнейших клинических, биохимических и эхокардиографических показателей, оцененных у пациентов к началу лечения ГД. В ретроспективный анализ были включены 213 больных (исключены больные с диабетической нефропатией), в качестве первого вида заместительной почечной терапии получавших лечение ГД. Длительность лечения ГД составила от 3,5 до 60 месяцев (27,4; 15,6-38,1). Суммарный срок наблюдения составил 479,2 человеко-лет, в течение которого было зафиксировано 43 смерти (20% всех наблюдений), пятилетняя выживаемость больных составила 68,6%, летальность - 9,0/100 пациенто-лет. При однофакторном анализе выявлено, что возраст старше 55 лет, снижение концентрации альбумина менее 35 г/л, высокие значения индекса коморбидности Charlson, наличие ишемической болезни сердца, превышение индекса массы левого желудочка к началу лечения ГД являются предикторами летального исхода. При многофакторном анализе с использованием модели Кокса, включающей все вышеназванные предикторы, наибольший вклад в прогноз летального исхода дают более чем 50% превышение индекса массы левого желудочка по сравнению с нормой (ОР 3,54, 95% ДИ 1,08-11,64) и показатели индекса коморбидности Charlson 5 и выше (ОР 3,59, 95% ДИ 1,19-10,84).

терминальная ХПН, программный гемодиализ, выживаемость, индекс коморбидности, гипертрофия миокарда левого желудочка, возраст, гипоальбуминемия, ишемическая болезнь сердца

1. Бикбов Б.Т., Томилина Н.А. О состоянии заместительной терапии больных с хронической почечной недостаточностью в Российской Федерации в 2001 г. Нефрология и диализ 2004; 6: 4-42.

2. Amar J., Vernier I., Rossignol E. et al. Nocturnal blood pressure and 24-hour pulse pressure are potent indicators of mortality in hemodialysis patients. Kidney Int 2000; 57: 2485-2491.

3. Bayes B., Pastor M.C., Bonal J. et al. Homocysteine, C-reactive protein, lipid peroxidation and mortality in haemodialysis patients. Nephrol Dial Transplant 2003; 18: 106-112.

4. Beddhu S., Bruns F., Saul M. et al. A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. Am J Med 2000; 108: 609-613.

5. Block G.A., Hulbert-Shearon T.E., Levin N.W. et al. Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic hemodialysis patients: a national study. Am J Kidney Dis 1998; 31: 607-617.

6. Bologa R.M., Levine D.M., Parker T.S. et al. Interleukine-6 predicts hypoalbuminemia, hypocholesterolemia and mortality in hemodialysis patients. Am J Kidney Dis 1998; 32: 107-114.

7. Bostom A.G., Shemin D., Verhoef P. et al. Elevated fasting total plasma homocysteine levels and cardiovascular disease outcomes in maintenance dialysis patients. Arterioscler Thromb Vasc Biol 1997; 17: 2554-2558.

8. Bryant D., Becker L., Richardson J. et al. Cardiac failure in transgenic mice with myocardial expression of TNFa. Circulation 1998; 97: 1375-1381.

9. Charlson M.E., Pompei P., Ales K.L. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987; 40: 373-383.

10. Cockcroft D.W., Gault M.H. Prediction of creatinine clearence from serum creatinine. Nephron 1976; 16: 31-35.

11. Devereux R.B., Reichek N. Echocardiographic determination of left ventricular mass in man: anatomic validation of the method. Circulation 1977; 63: 1391-1398.

12. Disney A.P.S. Demography and survival of patients receiving treatment for chronic renal failure in Australia and New Zeland. Am J Kidney Dis 1995; 25: 165-175.

13. Foley R.N., Parfrey P.S., Harnett J.D. et al. The impact of anemia on cardiomyopathy, morbidity, and mortality in end-stage renal disease. Am J Kidney Dis 1996; 28: 53-61.

14. Foley R.N., Parfrey P.S., Harnett J.D. et al. The prognostic importance of left ventricular geometry in the uremic cardiomyopathy. J Am Soc Nephrol 1995; 5: 2024-2031.

15. Foley R.N., Herzog C.A., Collins A.J. Blood pressure and long-term mortality in Unated States hemodialysis patients: USRDS Waves 3 and 4 Study. Kidney Int 2002; 62: 1784-1790.

16. Fried L., Bernardini J., Piraino B. Charlson comorbidity index as a predictor of outcomes in incident peritoneal dialysis patients. Am J Kidney Dis 2001; 37: 337-342.

17. Ganesh S.K., Stack A.G., Levin N.W. et al. Association of Elevated Serum PO4, Ca x PO4 Product, and Parathyroid Hormone with Cardiac Mortality Risk in Chronic Hemodialysis Patients. J Am Soc Nephrol 2001; 12: 2131-2138.

18. Garfray A., Patel K., Whitaker P. et al. Albumin as an outcome measure in hemodialysis patients: the effect of variation in assay method. Nephrol Dial Transplant 2000; 15: 1819-1822.

19. Guarnieri G., Antonione R., Biolo G. Mechanisms of malnutrition in uremia. J Ren Nutr 2003; 13: 153-157.

20. Hemmelgarn B.R., Manns B.J., Quan H. et al. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003; 42: 125-132.

21. Iseki K., Yamazato M., Tozawa M. et al. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int 2002; 61: 1887-1893.

22. Kaizu Y., Kimura M., Yoneyama T. et al. Interleukin-6 may mediate malnutrition in chronic hemodialysis patients. Am J Kidney Dis 1998; 31: 93-100.

23. Kaysen G.A., Chertow G.M., Adhikarla R. et al. Inflammation and dietary proteine intake exert competing effects on serum albumin and creatinine in hemodialysis patients. Kidney Int 2001; 60: 333-340.

24. Khan I.H., Campbell M.K., Cantarovich D. et al. Comparing Outcomes in Renal Replacement Therapy: How Should we Correct for Case Mix? Am J Kidney Dis 1998; 31: 471-478.

25. Kimmel P.L., Chawla L.S., Amarasinghe A. et al. Anthropometric measures, cytokines and survival in haemodialysis patients. Nephrol Dial Transplant 2003; 18: 326-332.

26. Leavey S.F., McCullough K., Hecking E. et al. Body mass index and mortality in «healthier» as compared with «sicker» haemodialysis patients: results from the dialysis outcomes and practice patterns study (DOPPS). Nephrol Dial Transplant 2001; 16: 2386-2394.

27. Leavey S.F., Strawerman R.L., Jones C.A. et al. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998; 31: 997-1006.

28. London G.M., Pannier B., Guerin A.P. et al. Alterations of left ventricular hypertrophy and survival of patients receiving hemodialysis: follow-up of an interventional study. J Am Soc Nephrol 2001; 12: 2759-2767.

29. Lowrie E.G., Lew N.L. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15: 458-482.

30. Lowrie E.G., Li Z., Ofsthun N. et al. Body size, dialysis dose and death risk relationships among hemodialysis patients. Kidney Int 2002; 62: 1891-1897.

31. Ma J.Z., Ebben J., Xia H. et al. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol 1999; 10: 610-619.

32. Mallamaci F., Zoccali C., Tripepi G. et al. Hyperhomocysteinemia predicts cardiovascular outcomes in hemodialysis patients. Kidney Int 2002; 61: 609-614.

33. Marcen R., Teruel J.L., de la Cal M.A. et al. The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Nephrol Dial Transplant 1997; 12: 2324-2331.

34. Mazzuchi N., Carbonell E., Fernandez-Cean J. ESRD patients without co-morbid risk factors at the start of haemodialysis are ideal as survival comparison population. Nephrol Dial Transplant 1999; 14: 1091-1096.

35. Mazzuchi N., Carbonell E., Fernandez-Cean J. Importance of blood pressure control in hemodialysis patient survival. Kidney Int 2000; 58: 2147-2154.

36. Merkus M.P., Jager K.J., Dekker F.W. et al. Predictors of poor outcome in chronic dialysis patients: the Nederlands cooperative study on the adequacy of dialysis. Am J Kidney Dis 2000; 35: 69-79.

37. Metcalfe W., Khan I.H., Prescott G.J. et al. Can we improve early mortality in patients receiving renal replacement therapy. Kidney Int 2000; 57: 2539-2545.

38. Owen W.F., Lew N.L., Liu Y. et al. The Urea Reduction Ratio and Serum Albumin Concentration as Predictors of Mortality in Patients Undergoing Hemodialysis. N Eng J Med 1993; 329: 1001-1006.

39. Owen W.F., Lowrie E.G. C-reactive protein as an outcome predictor for maintenance hemodialysis patients. Kidney Int 1998; 54: 627-636.

40. Parfrey P.S., Hamett J.D., Griffiths S.M. et al. The clinical course of left ventricular hypertrophy in dialysis patients. Nephron 1990; 55: 114-120.

41. Qureshi A.R., Alvestrand A., Danielssson A. et al. Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. Kidney Int 1998; 53: 773-782.

42. Qureshi A.R., Alvestrand A., Divino-Filho J.C. et al. Inflammation, Malnutrition, and Cardiac Disease as Predictors of Mortality in Hemodialysis Patients. J Am Soc Nephrol 2002; 13: S28-S36.

43. Raine A.E.G., Margreiter R., Brunner F.P. et al. Report on management of renal failure in Europe, XXII, 1991. Nephrol Dial Transplant 1992; 7 (Suppl 2): 7-35.

44. Reddan D.N., Klassen P.S., Szczech L.A. et al. White blood cells as a novel mortality predictor in haemodialysis patients. Nephrol Dial Transplant 2003; 18: 1167-1173.

45. Ridker P.M., Buring J.E., Shih T. et al. Prospective study of C-reactive protein and the risk of future cardiovascular events among apparently healthy women. Circulation 1998; 98: 731-733.

46. Ridker P.M., Cushman M., Stampfer M.J. et al. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Eng J Med 1997; 336: 973-979.

47. Ross R. Atherosclerosis - an inflammatory disease. N Eng J Med 1999; 340: 115-126.

48. Salem M.M. Hypertension in the haemodialysis population: any relationship to 2-years survival? Nephrol Dial Transplant 1999; 14: 125-128.

49. Savage D.D., Garrison R.J., Kannel W.B. et al. The spectrum of left ventricular hypertrophy in a general population sample: The Framingham Study. Circulation 1987; 75 (Suppl 1): I26-I33.

50. Shinzato T., Nakai S., Akiba T. et al. Survival in long-term haemodialysis patients: results from the annual survey of the Japanese Society for Dialysis Therapy. Nephrol Dial Transplant 1997; 12: 884-888.

51. Silberberg J.S., Barre P., Prichard S. et al. Impact of left ventricular hypertrophy on survival in end-stage renal disease. Kidney Int 1989; 36: 286-290.

52. Stack A.G., Saran R. Clinical correlates and mortality impact of left ventricular hypertrophy among new ESRD patients in the United States. Am J Kidney Dis 2002; 40: 1202-1210.

53. Stenvinkel P., Heimburger O., Paultre F. et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 1999; 55: 1899-1911.

54. Suliman M.E., Qureshi A.R., Barany P. et al. Hyperhomocysteinemia, nutritional status, and cardiovascular disease in hemodialysis patients. Kidney Int 2000; 57: 1727-1735.

55. The USRDS 1997 Annual Data Report. Causes of death. Am J Kidney Dis 1997; 30 (Suppl 1): S107-S117.

56. Wanner C., Metzger T. C-reactive protein a marker for all-cause and cardiovascular mortality in haemodialysis patients. Nephrol Dial Transplant 2002; 17 (Suppl 8): 29-32.

57. Yeun J.Y., Levine R.A., Mantadilok V. et al. C-reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis 2000; 35: 469-476.

58. Yokoyama T., Nakano M., Bednarczyk J.L. et al. TNF-α provokes a hypertrophic growth response in adult cardiac myocytes. Circulation 1997; 95: 1247-1252.

59. Zimmerman J., Herrlinger S., Pruy A. et al. Inflammation enhances cardiovascular risk and mortality in haemodialysis patients. Kidney Int 1999; 55: 648-658.

60. Zoccali C., Benedetto F.A., Mallamaci F. et al. Prognostic impact of the indexation of left ventricular mass in patients undergoing dialysis. J Am Soc Nephrol 2001; 12: 2768-2774.

61. Zoccali C., Bode-Boger S.M., Mallamaci F. et al. Plasma concentrations of asymmetrical dimethylarginine and mortality in patients with end-stage renal disease: a prospective study. Lancet 2001; 358: 2113-2117.