Jun 01, 2023
URR의 예후 가치는 모든 사람의 Kt/V와 동일합니다.
과학 보고서 13권,
Scientific Reports 13권, 기사 번호: 8923(2023) 이 기사 인용
65 액세스
1 알트메트릭
측정항목 세부정보
Kt/V 및 URR(요소 감소 비율) 측정은 투석의 적절성을 나타냅니다. 단일 풀 Kt/V는 이론적으로 우수한 방법이며 신장 질환 결과 품질 계획(Kidney Disease Outcomes Quality Initiative) 지침에서 권장됩니다. 그러나 모든 원인에 의한 사망률에 대해 Kt/V와 비교한 URR의 예후 가치는 알려져 있지 않습니다. 두 매개변수의 효과 수정자와 차단 값은 비교되지 않았습니다. 우리는 URR이 72%이고 Kt/V(Daugirdas)가 1.6인 혈액투석 환자 2,615명을 조사했습니다. 환자의 평균 연령은 59세였으며, 50.7%가 여성이었으며, 10년 이내에 1,113명(40.2%)이 사망하였다. URR과 Kt/V는 모두 영양 요인 및 여성 성과 긍정적인 관련이 있었고 체중 및 심부전과 부정적인 관련이 있었습니다. 모든 원인에 의한 사망률에 대한 Cox 회귀 모델에서 높은 URR 그룹(65~70%, 70~75%, > 75%)과 URR < 65% 그룹의 위험 비율(HR)은 0.748(0.623~0.623~65%)이었습니다. 각각 0.898), 0.693(0.578~0.829), 0.640(0.519~0.788)입니다. 높은 Kt/V 그룹(Kt/V 1.2–1.4, 1.4–1.7 및 > 1.7)과 Kt/V < 1.2 그룹의 HR은 0.711(0.580–0.873), 0.656(0.540–0.799) 및 0.623( 0.498–0.779), 각각. 하위그룹 분석에서 Kt/V는 여성의 모든 원인으로 인한 사망과 관련이 없었습니다. 모든 원인에 의한 사망률에 대한 URR의 예후 가치는 Kt/V만큼 큽니다. URR > 70% 및 Kt/V > 1.4는 더 높은 생존율과 관련이 있었습니다. Kt/V는 여성의 예후 가치가 더 낮을 수 있습니다.
투석 부적절함은 혈액투석(HD) 환자의 이환율과 사망률에 영향을 미칩니다1,2. 투석 부적절성은 소분자 및 중분자 제거3,4, 산-염기 및 전해질 균형, 체액 상태5 등 다양한 방식으로 평가할 수 있습니다. 요소 제거율은 Kt/V 및 URR(요소 감소율)을 포함한 측정을 통해 임상 실습5에서 투석 적절성을 측정하는 데 가장 강력하게 권장되는 측정 방법입니다. Kt/V [K: 투석기 클리어런스(mL/min); t: 투석 시간(분); V: 요소 분포량(mL)]은 Frank Gotch와 John Sargent6에 의해 개발되었으며 1990년대 Daugirdas에 의해 추가로 평형화되었습니다7. 이는 투석 적절성의 주요 지표로 남아 있습니다5,8. 2002년 획기적인 무작위 대조 시험인 HEMO 연구에서는 단일 풀 Kt/V(spKt/V) > 1.2가 HD 환자의 사망률 감소와 관련이 있음을 발견했습니다9. KDOQI(신장 질환 결과 품질 이니셔티브) 지침에서는 매주 3회 치료를 받는 환자에 대해 HD 세션당 목표 spKt/V 1.4를 권장하며, 최소 전달 spKt/V는 1.25입니다. URR은 1991년 Lowrie와 Lew가 개발한 비교적 간단한 방정식을 사용하여 계산됩니다10. 다양한 연구에 따르면 URR의 권장 복용량은 > 65%에서 > 75%까지입니다11,12. Taiwan Society of Nephrology는 임상 실습에서 URR을 사용하며 최소 요구 사항으로 URR > 65%를 제안합니다.
Kt/V에 비해 URR에 대해 HD 동안 달성된 선량 범위가 더 좁은 이유 때문에 두 매개변수(Kt/V는 요소 분포량과 UF를 고려하기 때문에)13와 URR 사이의 곡선 관계의 변화는 연속 신장 대체 동안 실질적으로 감소합니다. 치료법8. Kt/V는 오랫동안 HD 용량 처방 표준으로 URR보다 선호되어 왔으며 KDOQI5,8에서 권장됩니다. 그러나 Kt/V에는 장점을 극복할 수 있는 잠재적인 단점도 있으며 최근 수십 년 동안 논의되어 왔습니다.
체내 요소분포량을 고려한 Kt/V가 URR보다 더 정확하다고 생각됩니다. 그러나 V와 Kt는 모두 생존 관련 요인으로 간주되어 상쇄 효과를 일으킬 수 있습니다. 예를 들어, 질량이 낮은 환자의 경우 V가 낮기 때문에 높은 Kt/V가 더 쉽게 발생하며 이로 인해 투석 용량이 과대평가됩니다16,17. Kt/V와 URR 사이의 연관성을 확립하려는 연구가 시도되었지만, 한외여과(UF) 수준과 투석 시간으로 인해 측정값을 정확하게 변환할 수 없습니다8,18. Kt/V의 예후 가치는 이론적으로 URR의 예후 가치보다 높지만 직접적인 비교는 이루어지지 않았습니다.
75%) and Kt/V (< 1.2, 1.2–1.4, 1.4–1.7, > 1.7) levels, we found that more than half of the pa-tients had higher dialysis dose: 62.3% of patients had URR > 70%, and 69% of patients had Kt/V > 1.4. High-flux dialyzers were used in most of the patients during hemodialysis (98.7%), while low-flux dialyzers were more in patients with low URR or low Kt/V, but in very low percentage (1.3%). We observed that higher URR or Kt/V levels were associated with fe-male sex, higher age, absence of diabetes, and lower BW. Higher URR and Kt/V levels were both associated with higher nutritional markers (nPCR and total cholesterol) but lower WBC count and serum creatinine./p> 75% groups, respectively, and 110 (41.2%), 183 (33.7%), 326 (31.9%), and 247 (31.6%) deaths occurred in the Kt/V < 1.2, 1.2–1.4, 1.4–1.7, and > 1.7 groups, respectively. The lowest mortality rates among patients were of those who received URR of 70–75% and Kt/V > 1.7. Mortality rates were significantly higher for all cohort populations withURR < 70% vs > 70% (35.4% vs 31.7%)and Kt/V < 1.4 vs > 1.4(36.1% vs 31.7%; Table 1). In all study populations after adjustment, both higher URR (70–75%, > 75%)and Kt/V (1.4–1.7, > 1.7) groups had lower risk of all-cause mortality with adjusted hazard ratios (HRs) of 0.693 (95% confidence interval CI 0.578–0.829, P < 0.001) and 0.640 (95% CI 0.519–0.788, P < 0.001) in the URR group and 0.656 (95% CI 0.540–0.799, P < 0.001) and 0.623 (95% CI 0.498–0.779, P < 0.001) in the Kt/V group, compared with the URR < 65% and Kt/V < 1.2 groups. Although no matter higher Kt/V or URR groups both associated with lower HR, the effect of reduction of HR attenuating as in higher Kt/V or URR group. Moreover, each1SD increase in URR and Kt/V was associated with HRs of 0.896 (95% CI 0.844–0.952, P < 0.001) and 0.885(95% CI 0.824–0.952, P < 0.001), respectively (Table 3)./p> 1.2, single-pool Daugirdas formula or URR > 65%) were both associated with lower all-cause mortality compared with lower dialysis dose (Kt/V < 1.2, single-pool Daugirdas formula or URR < 65%). Moreover, in subgroup analysis, we found that higher dialysis dose was significantly associated with mortality in those with Kt/V < 1.4 but not in those with Kt/V ≥ 1.4. Kt/V was not associated with mortality in women./p> 1.2 is associated with better survival28,29. Studies have also suggested targeting Kt/V > 1.4 to achieve a minimum of Kt/V > 1.2 due to barriers to adequate delivery, such as lower blood flow, shorter time, recirculation, and use of a catheter for vascular access30,31. The KDOQI Clinical Practice Guideline for Hemodialysis Adequacy8 suggests a minimum URR dose of > 65% and a target dose of > 70% for patients receiving HD three times per week with treatment times less than 5 hours8. Barriers to URR and Kt/V correlation have been indicated, including higher UF, which may cause increased Kt/V, and long dialysis time, which may cause decreased URR8,18. Another study found that after stratifying patients into three BMI (body mass index) groups (low, medium, and high), the relative risk (RR) decreased when URR increased. Furthermore, patients treated with URR > 75% had a substantially lower RR than patients treated with URR 70–75% (P < 0.005 for medium and low BMI groups)12. Although patients benefit from higher Kt/V or URR, Chertowet al. demonstrated that patients with extremely high URR (> 75%) or single-pooled Kt/V (> 1.6) may be more severely malnourished, which may increase mortality and limit the utility of URR or Kt/V32. In our study, we found that URR > 70% or Kt/V > 1.4 was associated with better survival. In the subgroup analysis, we found that higher dialysis dose was significantly associated with mortality in those with Kt/V < 1.4 but not in those with Kt/V ≥ 1.4 which is compatible with the attenuation of HR we found in higher Kt/V or URR group in Table 3. However careful evaluation of the nutritional status of patients is also crucial./p> 75%) or single-pooled Kt/V (> 1.6) values (manifested in a lower V) due to malnutrition outweighed the benefits of greater urea clearance32. Moreover, studies also found that female HD patients tended to have more severe malnutrition35 and lower albumin levels36,outweighing the benefits of relatively high Kt/V. Due to this malnutrition factor, it is difficult to evaluate the actual benefits of increased dialysis dosage in women by using Kt/V. Our study found that sex modified the association between either Kt/V or URR and all-cause mortality, but BW did not. However, the conversion of BW to V was based on the Watson formula, which was designed in relation to a healthy Western population and might not reflect actual V in our study population37,38. In a later analysis in the HEMO study, increasing dialysis dose (double-pool Kt/V 1.53 vs double-pool Kt/V 1.16) in a subgroup of women reduced mortality by 19%; it did not cause a significant difference in men. This result persisted after adjustment for the interaction of dosage with body water volume or with other mass parameters, including weight and body mass index, which indicates that factors other than body size may have contributed to this result22. Another study found a similar sex difference in mortality benefit for women on HD in Japan with spKt/V levels ≥ 1.639. Although the previous studies were all favorable of underdialysis of woman in Kt/V, which is opposite to our result that no obvious prognosis value for woman with higher Kt/V, but in man. However, these studies all undeniably point out that sex difference did exist when using Kt/V. The mechanism of the sex difference modifying the association between Kt/V and all-cause mortality in our study remains unclear and maybe relate to race or specific population in our study. However, an optimal indicator for mortality should not generally be affected by age, sex, or comorbidities. Therefore, URR may have prognostic value for mortality equal to or greater than Kt/V, as shown in this study./p> 70%) and Kt/V (Kt/V > 1.4) were both associated with lower all-cause mortality in incident HD patients. Larger studies to compare the prognostic value of URR and Kt/V for mortality and more application of URR in the future studies are necessary. In addition, the prognostic value of Kt/V in women may warrant further investigation./p> 1.4) as suggested by KDIGO achieved. However, we will increase the surface area dialyzer if the minimal requirement of URR(> 65%) or Kt/V (> 1.2) were not achieved according to the guideline of Taiwan Society of Nephrology./p>
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