【摘要】虽然血液透析(hemodialysis,HD)治疗可以提高终末期肾病(end stage renal disease，ESRD)患者的预期寿命，但是与普通人群相比，透析患者死亡风险仍然显著增加。本研究旨在探究中国透析预后与实践模式研究(Dialysis Outcomes and Practice Patterns Study, DOPPS)中HD 患者死亡原因及死亡特点。方法DOPPS 是1 项国际性的前瞻性观察研究，中国参加了DOPPS 5 期研究(2012～2015 年)，并完成了队列的随访。中国DOPPS 5 中纳入了1427 名患者。以这些患者为研究对象，收集人口统计学、实验室检查、死亡日期、死亡原因等指标。明确患者死亡原因及死亡时间、地点等特点。结果DOPPS 5 期研究中共纳入1427 名HD 患者，其中北京473例，广州454例，上海500例。患者平均年龄为(59.4±14.9)岁，男性占55.0%，糖尿病患者占25.1%。平均随访时间为1.9 (1.1, 2.1)年。在随访期间共205名患者发生死亡，患者总体死亡率为14.4%，年平均死亡率为8.8%。死亡患者的中位年龄为70(59,79)岁；男性比例为56.1%，中位透析龄为2.5(1.0～5.0)年。北京、广州、上海死亡患者数分别为67, 67, 71 例，年平均死亡率分别为7.9%，10.0%以及8.6%。导致HD 患者死亡的前3 位病因分别为：脑血管意外(含缺血性卒中，19.3%)、充血性心力衰竭(18.2%)和肺部感染(11.6%)。心血管死亡总计为105 例，占51.2%。主要死亡原因排序有性别差异。血液透析死亡患者中70.8%于医院死亡，27.0%患者在家中发生死亡；79.8%患者没有停止血液透析，20.2%患者死亡前停止了HD 治疗。死亡患者中高达62.9%患者在死
亡前接受了临终关怀治疗。1天中10pm～6am 时段患者死亡风险最高。结论在中国DOPPS 5 期研究中，患者年平均死亡率为8.8%，其中心血管死亡是最主要的原因。在单项死亡原因中脑血管意外(含缺血性卒中)、充血性心力衰竭和肺部感染为最常见的3 种病因，且死亡的病因似乎具有性别差异。大部分患者为可预见的临终状态，1/4 的患者在家中死亡，在无医疗干预情况下，患者夜间凌晨死亡风险最高。
赵新菊
,
甘良英
,
牛庆雨
,
Yuqing Chen
,
侯凡凡
,
倪兆慧
,
陈晓农
,
梁馨苓
,
左力
. 中国血液透析患者死亡原因及特点分析-DOPPS 研究的启示[J]. 中国血液净化, 2022
, 21(02)
: 89
-93
.
DOI: 10.3969/j.issn.1671-4091.2022.02.005
【Abstract】Although hemodialysis (HD) can improve the life expectancy of end stage renal disease (ESRD) patients, the risk of death is still significantly higher in HD patients than in general population. The purpose of this study was to explore the cause of death and its related information in HD patients in the China Dialysis Outcomes and Practice Patterns Study (DOPPS). Methods DOPPS is an international, prospective and observational study. China participated in the DOPPS 5 study (2012～2015) and has completed the follow-up of the cohort. A total of 1,427 patients were enrolled in the China DOPPS 5 study. Their demographics,
primary cause of ESKD, comorbidities, dialysis prescription, laboratory examination results, and date, cause and other related information of death were recruited. The primary cause, date and place of death were then defined. Results A total of 1,427 HD patients were enrolled in the China DOPPS 5 study, including 473 cases in Beijing, 454 cases in Guangzhou and 500 cases in Shanghai. The average age of the patients was 59.4+14.9 years old, 55% were males, and 25.1% had diabetes. The mean follow-up period was 1.9 years (1.1, 2.1 years). During the follow-up period, 205 patients died, with the overall mortality of 14.4% and the annual average mortality of 8.8%. In the death patients, the median age was 70 (59, 79) years old, 56.1% were males, and the median dialysis vintage was 2.5 (1.0～5.0) years. The number of death patients in Beijing, Guangzhou and Shanghai were 67, 67 and 71 cases respectively, with the annual average mortality of 7.9%,10.0% and 8.6% respectively. The top three causes of death in HD patients were cerebrovascular events (19.3%, including ischemic stroke), congestive heart failure (18.2%) and pulmonary infection (11.6%); 105 cases died of cardiovascular diseases, accounting for 51.2% of the death patients. There were gender differences in the ranking of the main causes of death. In the died patients, 70.8% died in hospital and 27.0% died at home; HD treatment continued before death in 79.8% patients, and discontinued before death in 20.2%; 62.9% cases received
hospice care before death; the risk time of death in a day was within 10pm～6am. Conclusion In the China DOPPS 5 study, the average annual mortality was 8.8%. The main cause of death was cardiovascular events. Among the single cause of death, cerebrovascular events (including ischemic stroke), congestive heart failure and pulmonary infection were the most common causes of death, and the causes of death seemed to be gender different. The terminal stage was present in most death patients, and 1/4 of death happened at home. Without medical intervention, the risk time of death in a day was from late night to early morning.
参考文献
[1] Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017[J]. Lancet, 2020,395:709-733.
[2] Yang C, Gao B, Zhao X, et al. Executive summary for China Kidney Disease Network (CK-NET) 2016 Annual Data Report[J]. Kidney Int, 2020,98:1419-1423.
[3] Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in the United States[J]. Am J Kidney Dis, 2020,75:A6-A7.
[4] Cheng X, Nayyar S, Wang M, et al. Mortality rates among prevalent hemodialysis patients in Beijing: a comparison with USRDS data[J]. Nephrol Dial Transplant, 2013,28:724-32.
[5] 徐冷楠, 陈献广, 李天慧, 等. 单中心20年间维持性血液透析患者死亡原因分析[J]. 中华老年医学杂志, 2018,37:1111-1114.
[6] 徐彩棉, 夏国宏, 李轶洁. 单中心维持性血液透析患者死亡原因分析[J]. 中日友好医院学报, 2017,31:31-33.
[7] 高爱芹, 邹作君, 李垟, 等. 维持性血液透析患者死亡原因及其相关因素分析[J]. 中国血液净化, 2009,8:486-489.
[8] 闵永龙, 费世枝, 何达, 等. 武汉市血液透析死亡患者流行病学分析[J]. 中国血液净化, 2020,19:562-565.
[9] 武晴文, 李昊桐, 赵朵, 等. 山西省维持性血液透析患者预后调查(2013年～2016年)[J]. 肾脏病与透析肾移植杂志, 2019,28:119-123.
[10] 邹杨, 温玉, 蒲蕾, 等. 四川省新增血液透析患者的流行病学调查(2011年～2016年)[J]. 肾脏病与透析肾移植杂志, 2018,27:311-314+395.
[11] Fotheringham J, Fogarty DG, El Nahas M, et al. The mortality and hospitalization rates associated with the long interdialytic gap in thrice-weekly hemodialysis patients[J]. Kidney Int, 2015,88:569-75.
[12] Foley RN, Gilbertson DT, Murray T, et al. Long interdialytic interval and mortality among patients receiving hemodialysis[J]. N Engl J Med, 2011,365:1099-107.
[13] Karnik JA, Young BS, Lew NL, et al. Cardiac arrest and sudden death in dialysis units[J]. Kidney Int, 2001,60:350-7.
[14] Siga MM, Ducher M, Florens N, et al. Prediction of all-cause mortality in haemodialysis patients using a Bayesian network[J]. Nephrol Dial Transplant, 2020,35:1420-1425.
[15] 何明丰, 梁章荣, 张继平, 等. 180例急性中风病例死亡时间的圆形统计分析[J]. 中国中西医结合急救杂志, 2006:206-209.
[16] Vicent L, González-Casal D, Bru?a V, et al. Circadian Rhythm of Deaths in a Cardiology Department: A Five-Year Analysis[J]. Cardiology, 2020,145:344-349.
[17] Tislér A, Logan AG, Akócsi K, et al. Circadian variation of death in hemodialysis patients[J]. Am J Kidney Dis, 2008,51:53-61.
[18] Stirnadel-Farrant HA, Karaboyas A, Cizman B, et al. Cardiovascular Event Rates Among Hemodialysis Patients Across Geographical Regions-A Snapshot From The Dialysis Outcomes and Practice Patterns Study (DOPPS)[J]. Kidney Int Rep, 2019,4:864-872.
[19] Tsujimoto Y, Tsutsumi Y, Ohnishi T, et al. Low Predialysis Plasma Calculated Osmolality Is Associated with Higher All-Cause Mortality: The Japanese Dialysis Outcomes and Practice Patterns Study (J-DOPPS)[J]. Nephron, 2020,144:138-146.
[20] Robinson BM, Akizawa T, Jager KJ, et al. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices[J]. Lancet, 2016,388:294-306.
[21] Zhou M, Wang H, Zeng X, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017[J]. Lancet, 2019,394:1145-1158.
[22] Peter-Derex L, Derex L. Wake-up stroke: From pathophysiology to management[J]. Sleep Med Rev, 2019,48:101212.
