Luis Loureiro Harrison, Edouard L Fu, Peter C Thomson, Jamie P Traynor, Patrick B Mark, Sokratis Stoumpos
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引用次数: 0
摘要
背景：先前的非随机研究表明，动静脉瘘（AVF）的形成具有肾保护作用，但这些似乎容易受到时间和选择偏差的影响。方法：我们研究了2010-22年间在苏格兰西部肾脏病诊所就诊的患者，估计肾小球滤过率(eGFR)≤15 mL/min/1.73 m2，无AVF病史。使用目标试验模拟和顺序试验设计，我们模拟了一个假设的试验，将患者随机分组，要么立即进行AVF形成，要么不进行AVF形成。主要终点是随访前6个月eGFR斜率的差异，使用混合效应模型估计。次要结局是5年透析和死亡的绝对风险，分别使用aallen - johansen和Kaplan-Meier估计值进行估计。结果：共有1364例独特患者（平均年龄51.1岁，55.7%为男性）参与了3125例试验，其中561例为AVF组，2564例为无AVF组。平均eGFR为12.6 mL/min/1.73 m2，平均每人试验eGFR测量数为7（四分位数范围为4-12）。AVF组和无AVF组eGFR下降斜率无显著差异（组间差异为-0.67 mL/min/1.73 m2/年，95% CI为-1.43,0.10）。AVF组5年透析绝对风险为87% (95% CI 84, 91)，无AVF组为75% (95% CI 73, 77)， AVF组5年生存率为77% (95% CI 70, 83)，无AVF组为67% （95% CI 64, 69）。结论：在这项晚期慢性肾病患者的研究中，没有证据表明AVF形成具有肾保护作用。
Impact of arteriovenous fistula formation on trajectory of kidney function decline: a target trial emulation.
Background: Prior nonrandomized studies have suggested nephroprotective effects of arteriovenous fistula (AVF) formation, but these are plausibly susceptible to immortal time and selection biases.
Methods: We studied patients attending nephrology clinics in the West of Scotland during 2010-22 with an estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m2 and no prior AVF. Using target trial emulation and a sequential trial design, we simulated a hypothetical trial that would randomize patients to either undergo AVF formation immediately or not to undergo AVF formation. The primary outcome was the difference in eGFR slope for the first 6 months of follow-up, estimated using a mixed-effects model. The secondary outcomes were 5-year absolute risks of dialysis and death, estimated using the Aalen-Johansen and Kaplan-Meier estimators respectively.
Results: A total of 1364 unique patients (mean age 51.1 years, 55.7% male) contributed 3125 person-trials, with 561 in the AVF and 2564 in the no AVF group. Mean eGFR was 12.6 mL/min/1.73 m2 and the median number of eGFR measurements per person-trial was 7 (interquartile range 4-12). Slope of eGFR decline did not differ significantly between the AVF and no AVF groups (between-group difference -0.67 mL/min/1.73 m2/year, 95% CI -1.43, 0.10). The 5-year absolute risk of dialysis was 87% (95% CI 84, 91) in the AVF group and 75% (95% CI 73, 77) in the no AVF group, and the 5-year survival probability was 77% (95% CI 70, 83) in the AVF group and 67% (95% CI 64, 69) in the no AVF group.
Conclusions: In this study of patients with advanced chronic kidney disease, there was no evidence of a nephroprotective effect of AVF formation.
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About the Journal
Clinical Kidney Journal: Clinical and Translational Nephrology (ckj), an official journal of the ERA-EDTA (European Renal Association-European Dialysis and Transplant Association), is a fully open access, online only journal publishing bimonthly. The journal is an essential educational and training resource integrating clinical, translational and educational research into clinical practice. ckj aims to contribute to a translational research culture among nephrologists and kidney pathologists that helps close the gap between basic researchers and practicing clinicians and promote sorely needed innovation in the Nephrology field. All research articles in this journal have undergone peer review.
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