6. Crit Care Clin 2005;21:347– 356
RRT導入のタイミング
› 様々なEarly(BUN<60-100mg/dL) vs Late(BUN>100mg/dL)
で比較したCohort Studyがあり, 早期導入のほうが生存率は良好だが,
Cohortだと母集団のBiasが大きく, 評価は困難.
› 小規模のRCTでは両者で生存率は変わらないとの結果が主であり,
BUN>100mg/dLで導入, <80mg/dLに保つのが一般的となっている.
Study N Type BUN 死亡率
Kidney Int 1972;1:190-6 320 Retrospective 93 vs 164 29% vs 42%
J Trauma 1975;15:1056-63 18 Prospective Randomized 50 vs 120 20% vs 64%
Clin Nephrol 1986;25:249-55 34 Prospective Randomized 60 vs 101 58.8% vs 47.1%
7. 透析の早期導入は有害かもしれない
Arch Intern Med 2011;171:396-403
米国で透析導入(非DM性腎症)された81176名のCohort.
male sex, black race, and a BMI lower than 25.0 had a
› 導入時のeGFRと1年, 2年死亡率を比較.
negative effect on survival, whereas higher levels of he-
moglobin, later year of treatment, Asian race, and pri-
Table 2. First- and Second-Year Mortality for Incident
Population of Patients Undergoing Hemodialysis,
1996-2006, Ages 20 to 64 Years, Without DM and With No
mary etiology of PCKD or glomerular disease had a posi- Other Reported Comorbidity Except Hypertension
› eGFRが多いほど, 透析導入後の死亡率も高値.
tive effect on survival (PϽ.001 for all comparisons). These
effects were similar in the HG except for a survival ad- Year, Percentage
vantage for black race. Adjusted HRs for the overall popu- of Patients
› Alb値別による評価でも同様の結果.
lation by the 3 eGFR groups, relative to the reference
Group Patients, No. First Second a
group, were 1.23, 1.47, and 1.74, respectively, and for
the HG were 1.27, 1.53, and 2.18, respectively. All persons, % 81 176 9.40 7.10
We determined that both eGFR and serum albumin eGFR b
0-4.9 24 440 6.8 5.8
level had time-dependent effects on mortality (Figure). 5.0-9.9 43 474 9.1 7.2
› 所 Cohortであり,
The effect of early start was not as evident in the group
with low albumin level (Figure, A). The HR for persons
10.0-14.9 10 113 14.0 8.9
Ն15.0 3149 20.1 12.2
with an eGFR of 5.0 to 9.9 mL/min/1.73 m2 did not change
eGFRが高い状態でHD導入せざるを得なかった
greatly over time for all albumin-level groups. In the HG
Albumin level, g/dL
Ͻ2.5 12 040 21.0 12.1
group, the association of early start and poor relative sur- 2.5-3.49 33 471 10.1 8.0
理由があることを考慮すると, 当然の結果か.
vival is seen in the cohort with an eGFR of 15 mL/min/ Ն3.5
Albumin level, Ͻ2.5 g/dL
35 665 4.7 4.7
1.73 m2 or higher; the HR was 3.53 in the first 6 months eGFR Ͻ5.0 2996 16.9 11.2
and declined to 1.57 after 2 years. eGFR 5.0-9.9 6035 20.8 12.2
eGFR 10.0-14.9 2068 25.2 12.6
eGFR Ն15.0 941 26.6 13.8
COMMENT Albumin level, 2.5-3.4 g/dL
eGFR Ͻ5.0 19 846 7.0 5.9
4-11 eGFR 5.0-9.9 17 308 10.2 8.5
As shown in prior studies, the presence of reported eGFR 10.0-14.9 4052 15.0 10.2
comorbidity is strongly associated with lower survival. eGFR Ն15.0 1265 20.8 13.2
Lassalle et al9 found that only the patients with the high- Albumin level, Ն3.5 g/dL
est comorbidity were at greater risk of death with early eGFR Ͻ5.0 10 598 3.6 4.2
hemodialysis. Several large observational studies showed eGFR 5.0-9.9 20 131 4.5 4.6
a “dose-response” relationship between comorbidity lev- eGFR 10.0-14.9 3993 6.7 5.7
eGFR Ն15.0 9437 12.5 9.4
els and earlier hemodialysis initiation.6,11 In our rela-
8. 1678名の新規透析導入患者のCohort
› “Frailty” 衰弱; Slowness/weakness, exhaustion, low physical activityのそ
れぞれを評価し, ≥2/3を満たす場合にFrailtyと判断(SF-12による評価).
Table 2. Multivariate Model Examining Predictors of Frailty a
› 透析導入患者において,
Frail
Frailty(+) vs (-)を比較. Variable OR (95% CI) P Value
Age, per 10 y 1.00 (0.90-1.11) .98
Male sex 0.49 (0.39-0.62) Ͻ.001
White race 1.25 (0.96-1.62) .10
› 透析導入時のeGFRが Medicaid, vs other payers 1.70 (1.22-2.36) .002
Current smoker 1.27 (0.76-2.13) .36
5ml/min/1.73m2上昇毎に eGFR, per 5 mL/min/1.73 m2
increase
1.44 (1.23-1.68) Ͻ.001
Albumin quartiles/missing .37 for trend
Frailtyリスクも上昇(OR 1.44[1.23-1.68]) Group 1: Յ2.5 g/dL 0.98 (0.66-1.46) .92
Group 2: Ͼ2.5-3.0 g/dL 1.12 (0.78-1.61) .55
Group 3: missing 1.11 (0.80-1.54) .53
Group 4: Ͼ3.0-3.5 g/dL 1 [Reference]
Group 5: Ͼ3.5 g/dL 0.85 (0.61-1.20) .35
Hemoglobin quartiles/missing .07 for trend
Group 1: Յ9 g/dL 1 [Reference]
Group 2: Ͼ9-10 g/dL 1.07 (0.76-1.51) .69
Group 3: missing 0.99 (0.63-1.57) .97
Group 4: Ͼ10-12 g/dL 1.04 (0.77-1.42) .80
Group 5: Ͼ12 g/dL 1.61 (1.02-2.53) .04
Hemodialysis 1.04 (0.71-1.53) .84
Comorbidity
Diabetes mellitus 1.52 (1.18-1.96) .001
Congestive heart failure 1.27 (0.94-1.70) .11
Atherosclerotic heart disease 0.96 (0.68-1.34) .80
CVA/TIA 1.85 (1.04-3.28) .04
Peripheral vascular disease 1.67 (1.16-2.41) .006
Arch Intern Med 2012;172:1071-77 COPD 1.77 (0.96-3.25) .07
Cancer 8
1.19 (0.70-2.03) .52
20. SLEDの薬剤クリアランス
Table 3. Antimicrobial dosing recommendations during sustained low-efficiency dialysis
Drug Nebraska Medical Center Dosing Recommendationsa,b
Anidulafungin (66) No dosing adjustments necessary
Daptomycin (25, 26) Dose every 24 hrs on SLED
Dose every 48 hrs off SLED
Gentamicin (32, 38) Initial loading dose 6 mg/kg lean body weight every 48 hrs as a 30-
min infusion. Give 1 hr before SLED. Doses should be adjusted
according to serum concentrations observed during and after the
SLED sessionc
Non-ICU patients, dose every 24 hrs on SLED at approximately 2-2.5
mg/kg/dose (would recommend using ideal or adjusted body weight)
Dose per levels off SLED
Tobramycin–same recommendations
Amikacin 15-20 mg/kg lean body weight every 48 hrs. Doses should be
adjusted according to serum concentrations observed during and
after the SLED session.
Ertapenem (51) No dose adjustment needed
Meropenem, Meropenem 500-1000 mg IV every 8 hrs while on SLED
impenem (47) Imipenem 500 mg IV every 6 hrs while on SLED (if Ͼ70 kg)
Vancomycin (47, 48) Dose every 12-18 hrs while on SLED
Dose per levels off SLED
Linezolid (58) No dose adjustment needed
May consider supplemental dose or every 8 hrs dosing if continuous
SLED for some organisms
Moxifloxacin, Moxifloxacin–no adjustment needed
levofloxacin (61) Levofloxacin–adjustment may be necessary, no specific
recommendation
SLED, sustained low-efficiency dialysis; IV, intravenous; ICU, intensive care unit.
a
These recommendations are used in our institution based on evaluation and interpretation of the
literature and known properties of SLED. This information is not intended to replace clinical judgment
or experience in individual patients; bdialysis parameters include blood and dialysate flow rates each
set at 200 mL/min and the use of a high-flux polysulfone filter; cdialysis parameters include blood and
dialysate flow rates each set at 300 mL/min.
Crit Care Med 2011;39:560-70