比较血液透析(hemodialysis，HD)和腹膜透析(peritoneal dialysis，PD)患者的严重出血事件风险。 方法 前瞻性纳入2013年6月～2018年7月在平湖市中医院开始透析治疗的1745例终末期肾病(end stage renal disease，ESRD)患者。依据患者透析方式分为HD组(n=1211，69.4%)和PD组(n=534，30.6%)。对患者进行为期3年的随访。出血事件定义为在随访3年内出现导致住院或死亡的出血事件。使用Kaplan-Meier曲线分析和Log-rank法比较3年的随访中2组患者出血事件发生率的组间差异。采用含时间依存性自变量的COX回归分析模型计算调整协变量后的HD组与PD组患者发生出血事件的HR和95%CI。 结果 3年随访期间，共183例患者在开始透析后中位随访2.2(1.0，3.0)年出现首次出血事件。其中144例患者在基线期时接受HD，39例接受PD治疗。HD组患者累计出血发生率为15.5%，PD组为9.7%，组间差异有统计学意义(χ2=5.872，P =0.013)。含时间依存性自变量的COX回归分析显示，校正混杂因素后，与PD患者相比，HD患者出血风险调整HR为1.6(95% CI：1.2～2.5)，P=0.014。以未服用抗血栓药物的PD患者为参照，服用抗血栓药物的HD患者出血风险调整HR为2.0(95% CI:1.3～3.8)，P =0.002；以无心血管并发症的PD患者为参照，有心血管并发症的HD患者调整HR为1.9(95% CI:1.3～3.1)，P =0.022；以无既往出血史的PD患者为参照，既往有出血史的HD患者调整HR为3.2(95% CI:2.0～5.8)，P＜0.001。 结论 HD患者出血风险是PD患者的1.6倍。接受抗栓治疗、合并心血管疾病、既往有出血病史的HD患者发生严重出血的风险增加。
Objective To compare the risk of severe bleeding events in hemodialysis (HD) patients and peritoneal dialysis (PD) patients. Methods A total of 1,745 patients with end-stage renal disease (ESRD) who started dialysis treatment in Pinghu Hospital of Traditional Chinese Medicine from June 2013 to July 2018 were prospectively recruited. Patients were divided into HD group (n=1,211, 69.4%) and PD group (n=534, 30.6%) according to the dialysis method. They were followed up for 3 years. Demographic and clinical data were collected. Bleeding event was defined as the bleeding leading to hospitalization or death within the follow-up period of 3 years. Kaplan-Meier curve and log-rank test were used to compare the incidence of bleeding event between the two groups within the follow-up period of 3 years. Cox regression analysis with time-dependent independent variables was used to calculate the risk ratio (HR) and 95% confidence interval (95% CI) of bleeding events in HD and PD groups after adjusting for covariates. Results During the 3 years of follow-up, 183 patients had a first bleeding event within a median of 2.2 years (P25: 1.0, P75: 3.0). Of these bleeding patients, 144 received HD and 39 received PD in the baseline period. The cumulative incidence of bleeding event was 15.5% in HD group and 9.7% in PD group (log rank test: χ2=5.872, P=0.013). Cox regression analysis with time-dependent independent variables and after adjusting for confounding factors showed that the adjusted HR for bleeding risk in HD patients was 1.6 (95% CI: 1.2~2.5, P=0.014) as compared with PD patients; the adjusted HR of bleeding risk in HD patients taking antithrombotic drugs was 2.0 (95% CI: 1.3~3.8, P=0.002) as compared with the PD patients without antithrombotic drug treatment; the adjusted HR of bleeding risk in HD patients with cardiovascular complications was 1.9 (95% CI: 1.3~3.1, P=0.022) as compared with the PD patients without cardiovascular complications; the adjusted HR of bleeding risk in HD patients with previous bleeding history was 3.2 (95% CI: 2.0~5.8, P＜0.001) as compared with the PD patients without previous bleeding history. Conclusions The risk of bleeding event in HD patients was 1.6 times higher than that in PD patients. HD patients who received antithrombotic therapy, had cardiovascular disease, and had a history of bleeding were at a higher risk of severe bleeding.
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