延長透析時間無法改善生活品質


  【24drs.com】新研究顯示,延長每週血液透析的總時間,並不會影響生活品質,但是對血壓等其他參數有正面影響。
  
  觀察型研究認為每週延長透析時間可以改善生活品質、存活、與各種臨床和檢驗參數,多倫多大學健康網絡的Christopher Chan醫師表示,不過,這個議題的隨機控制試驗資料很少,對於可能的傷害仍是有所爭議的;他在美國腎臟協會第35屆透析年會發表其研究團隊的隨機控制試驗結果。
  
  這篇多國試驗在澳大利亞、加拿大、中國和紐西蘭等國的40個地點進行,延長時間組的100名病患中,血液透析目標是每週至少24小時、為期12個月;標準組的100名病患中,目標是每週10-15小時。
  
  研究對象每週須進行3次透析,頻率上沒有其他限制,每次洗腎時間或地點也沒有限制。
  
  使用「歐洲生活品質五面向量表(EuroQOL five-dimensions questionnaire,EQ-5D)」問卷評估主要結果—從開始時到12個月時的生活品質變化,每3個月由不知情的採訪者進行。
  
  次級結果包括:存活、心血管事件、其他生活品質測量、生物和血液替代品的改變、安全性與血管通路,以及顯示EQ-5D確認的好處之後的成本效果分析。
  
  開始時,研究對象平均年齡52歲,每週平均透析13.9小時,兩組的男性都多於女性。
  
  12個月時,延長時間組平均每週透析22.1小時,標準組平均每週14.2小時,延長時間組對於目標時間的遵守度低於標準組(74.2% vs 94.5%)。
  Chan醫師解釋,遵守度的結果不令人意外,讓人遵守延長時間一定有難度。
  
  延長時間組與標準組的生活品質測量跟開始時相比都沒有差異,Chan醫師報告指出,值得注意的是,兩組在開始時的生活品質分數0.76是相當高的,高於透析人口的預期。
  
  會議主持人、維吉尼亞州Lynchburg的腎臟內科醫師Robert Lockridge表示,他從這篇研究得到的關鍵是,就血液透析而言,時間與頻率造成差異;不過,令他驚訝的是,兩組之間沒有差異。
  
  他表示,有足夠的文獻顯示,支持「更加頻繁和更長的血液透析更好」的概念;這個議題在美國是個專門知識。
  
  兩組在12個月時的收縮壓沒有差異,不過延長時間組病患的降血壓藥數量有減少。
  
  相較於標準組,延長時間組的病患也有比較高的血色素、比較低的鉀和磷,紅血球生成刺激劑的需要量也比較低。
  
  兩組在12個月時的EQ-5D心智分數沒有差異。
  
  Chan醫師報告指出,生理方面的分數偏好延長透析,但是這些是次要結果。
  
  延長時間組的死亡人數比標準組多(5 vs 2),但是兩組的心血管以及血管通路事件是類似的 ,兩組都沒有發生嚴重的不良反應事件。
  
  根據這些資料,Chan醫師等人結論指出,延長血液透析時間與生活品質測量沒有關聯;不過,他們指出,對於其他檢驗參數的影響是正面的。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=7158&x_classno=0
  

Extending Dialysis Hours Fails to Improve Quality of Life

By Meg Barbor
Medscape Medical News

NEW ORLEANS — Increasing the hours of hemodialysis each week does not affect quality of life, but it does have a positive influence on other parameters, including blood pressure, new research has shown.

Observational studies have suggested that extending the weekly hours of dialysis improves quality of life, survival, and a variety of clinical and laboratory parameters. "However, few randomized controlled data exist on the topic, and there is still some debate" about possible harms, said Christopher Chan, MD, from the University Health Network in Toronto.

He presented results from his team's randomized controlled trial here at the American Society of Nephrology 35th Annual Dialysis Conference.

The multinational trial was conducted at 40 sites in Australia, Canada, China, and New Zealand. For the 100 patients in the extended group, the hemodialysis target was at least 24 hours each week for 12 months; for the 100 patients in the standard group, the target was 10 to 15 hours each week.

Participants were required to undergo three dialysis sessions every week, but there were no other restrictions on frequency, and there were no restrictions on the duration or location of the sessions.

The primary outcome — change in quality-of-life measures from baseline to 12 months — was evaluated with the EuroQOL five-dimensions questionnaire (EQ-5D), which was administered by a blinded interviewer every 3 months.

Secondary outcomes included survival, cardiovascular events, other quality-of-life measures, change in biologic and hematologic surrogates, safety and vascular access, and cost–utility after the demonstration of EQ-5D-determined benefit.

At baseline, mean age of the participants was 52 years and mean duration of weekly dialysis was 13.9 hours. There were more men than women in both the extended and standard groups.

At 12 months, mean duration of weekly dialysis was 22.1 hours in the extended group and 14.2 hours in the standard group. Adherence to the target hours was worse in the extended group than in the standard group (74.2% vs 94.5%)

"The adherence pattern isn't that surprising," Dr Chan explained. "It has always been difficult to get people to adhere to extended hours."

Surprise Finding

There was no difference in the change in quality-of-life measures from baseline between the extended and standard groups. "However, it is notable that the baseline QOL score of 0.76 was quite high in both groups, and higher than expected in the dialysis population," Dr Chan reported.

"The key thing I learned from this study is that in terms of hemodialysis, time and frequency make a difference," said session moderator Robert Lockridge, MD, from Lynchburg Nephrology Physicians in Virginia.

However, he added, "it is surprising to me that there was no difference between the two groups."

"There's enough literature out there to support the notion that more frequent and longer hemodialysis is better; the issue in the United States is know-how," he told Medscape Medical News.

There was no difference in systolic blood pressure at 12 months between the two groups, although there was a decrease in the number of blood-pressure-lowering agents patients in the extended group were receiving.

Patients in the extended group also had higher levels of hemoglobin and lower levels of potassium and phosphate than those in the standard group, and required lower doses of erythropoiesis-stimulating agents.

There was no significant difference between groups in the EQ-5D mental score at 12 months.

"The difference in physical score favored extended dialysis," Dr Chan reported, "but this is a secondary outcome."

There were more deaths in the extended group than in the standard group (5 vs 2), but cardiovascular events were similar in the two groups, as was vascular access. No significant serious adverse events occurred in either group.

On the basis of these data, Dr Chan and his colleagues conclude that there is no correlation between extended hemodialysis hours and quality-of-life measures; however, they note, the impact on several other laboratory parameters is positive.

Dr Chan reports financial relationships with Baxter International and Intelomed. Dr Lockridge has disclosed no relevant financial relationships.

American Society of Nephrology 35th Annual Dialysis Conference: Abstract HI-OR08. Presented January 31, 2015.

    
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