Kronik hemodiyaliz tedavisi gören hastaların yaşam süreleri ve buna etki eden faktörler
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Abstract
33 ÖZET Bu çalışma İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Hemodiyaliz Ünitesi'nde 1989 ve 2001 yıllan arasında en az 3 ay kronik hemodiyaliz programına alınan toplam 172 hastanın sürvilerini bulmak ve bu survive etki eden faktörleri ortaya çıkarmak için yapılmıştır. Hasta populasyonunun ortalama yaşı 45.35 idi. Hastaların 109 tanesi (%63) erkek, 63 tanesi (%37) kadındı. Hastaların 10 tanesi (%6) haftada 1, 108 tanesi (%63) haftada 2, 54 tanesi (%3 1) haftada 3 kez hemodiyaliz tedavisi görmüştü. Hastaların kronik böbrek yetersizliği etiyolojisine bakıldığında nedeni kesin olarak bilinmeyenler 59 hasta ile (%34.3) ön sırada yer almaktaydı. Daha sonra sırasıyla 22 (%12.8) hasta ile kronik glomerulonefrit, 21 (%12.2) hasta ile diyabetik nefropati, 17 (%9.8) hasta ile hipertansiyon, 16 (%9.3) hasta ile interstisiyel nefropati, 10 (%5.8) hasta ile sistemik vaskülit, 9 (%5.2) hasta ile ailevi akdeniz ateşine bağlı sekonder amiloidoz, 5 (%3) hasta ile obstrüktif nefropati, 5 (%3) hasta ile polikistik böbrek gelmekteydi. Hemodiyaliz tedavisine başlamadan önce değerlendirilen Karnofsky performans skorları; 31 (%18) hastada 0, 45 (%26) hastada 1, 61 (%35) hastada 2, 33 (%19) hastada 3, 2 (%1) hastada 4 idi. Hastaların ortalama serum albümin düzeylerine göre gruplandınlan nütrisyonel durumları; 15 hasta kötü (alb<3mg/dl), 22 hasta orta (alb=3- i 5mg/dl), 52 hasta iyi (alb>3.5mg/dl) bulundu. 46 hastada ko-morbidite saptanmaz iken, 108 hastada ise kardiyovasküler morbidite mevcuttu. Diğer ko-morbiditeler ise santral sinir sistemi hastalığı, periferik vasküler hastalık, neoplastik hastalık, tüberküloz ve diğer morbiditeler olarak saptandı. 17 hastada 2 adet, 3 hastada 3 adet ko-morbidite bulunmaktaydı. Ayrıca incelenen kardiyovasküler morbidite durumuna göre; 98 hastada hipertansiyon, 40 hastada İKH, 37 hastada KKY mevcuttu. 23 hastada 2 kardiyovasküler morbidite 3 hastada ise 3 kardiyovasküler morbidite birlikte bulunmaktaydı. Hastaların sistemik arteriyel kan basınçları ortalaması; diyaliz öncesi sistolik arteriyel kan34 basıncı 144.95mmHg, diyaliz öncesi diyastolik arteriyel kan basıncı 86.95mmHg, diyaliz öncesi O AB 106.34mmHg, diyaliz sonrası sistolik arteriyel kan basıncı 142.16mmHg, diyaliz sonrası diyastolik arteriyel kan basıncı 93mmHg, diyaliz sonrası OAB 102.05mmHg olarak bulundu. 172 hastadan 61 'i antihipertansif ilaç kullanıyordu. 69 hastanın hepatit serolojisi ile ilgili kayıt vardı; 25 hasta HBs Ag (+), 13 hasta anti-HBs Ab (+), 31 hasta anti-HCV (+) idi. Hastaların ortalama hematokrit düzeyleri %27.8, ortalama albumin düzeyleri 3.1mg/dl, ortalama total kolesterol düzeyleri 97.26mg/dl, ortalama LDL düzeyleri 53.14mg/dl, ortalama diyaliz öncesi üre düzeyleri 210.22mg/dl, ortalama diyaliz sonrası üre düzeyleri 97.75mg/dl, ortalama kreatinin düzeyleri 6.66mg/dl idi. UKM parametrelerinden Kt/V ortalaması tüm hastalarda 1. l/gün idi. Diğer bir UKM parametresi olan URR ortalaması %56 idi. Hastaların 5 ve 10 yıllık sürvileri Kaplan-Meier yöntemine göre %42 ve %25.3 olarak bulundu. Selwood yöntemine göre yani yaşam süresi hesaplanması modifiye edilip diğer tedavi modalitelerine ve merkezlerine geçen hastalar da gözönüne alındığında sürvi 5 yılda %46.2, 10 yılda %32.4 olduğu bulundu. Haftada 3 kez girenlerin 5 yıllık sürvisi (%43.2) 1 veya 2 kez girenlerden (%41.8) daha iyiydi ancak fark istatistiksel olarak anlamlı değildi. Diyabetik nefropatili hastaların sürvisi (%28.2) diyabetik olmayan hastalara (%45.3) göre daha kötüydü ve fark anlamlıydı (p=0.02). Cox-Regresyon Hazard Modeline göre hastaların sürvilerine anlamlı etkisi olan faktörler olarak ortalama serum albümin değeri (p=0.001), ortalama hematokrit değeri (p=0.001), diyaliz sonrası ortalama diyastolik arteriyel kan basıncı (p=0.01), ortalama kreatinin düzeyi (p=0.01), yaş (p=0.02), Karnofsky performans skoru (p=0.02), diyaliz öncesi ortalama diyastolik arteriyel kan basıncı (p=0.02), kardiyovasküler morbidite varlığı (p=0.03)5 sadece KKY varlığı (p=0.02), herhangi 3 kardiyovasküler morbiditenin birlikte bulunması (p=0.01), diyaliz öncesi OAB (p=0.05), ortalama Kt/V (p=0.05) bulundu.35 Cinsiyet, ağırlık, sigara, kooperasyon, diyaliz öncesi sistolik kan basıncı, diyaliz sonrası hem sistolik hem diyastolik kan basınçları, kardiyovasküler morbidite hariç diğer ko- morbiditelerin hastaların sürvisine olan etkileri istatistiksel olarak anlamsız bulunmuştur. 36 SUMMARY This study was planned to determine the survival and factors affecting the survival in 172 patients who were under chronic hemodialysis treatment at least for 3 months in Istanbul University Cerrahpaşa Faculty of Medicine Hemodialysis Unit between 1989 and 2001. The mean age of the patient population was 45.35. Male:female ratio was 109:63. 10 (6%) patients were taking the treatment once a week, 108 (63%) of them were taking the treatment twice a week and 54 (31%) of them thrice a week. Etiology of chronic renal failure was unknown in 59 (34.3%) of the patients. It was chronic glomerulonephritis in 22 (%12.8) diabetic nephropathy in 21 (12.2%), hypertension in 17 (9.8%), interstitial nephropathy in 16 (9.3%), systemic vasculitis in 10 (5.8%), secondary amyloidosis due to familial mediterranean fever in 9 (5.2%), obstructive uropathy in 5 (3%), polycystic kidney disease in 5 (3%) of the patients. Karnofsky performance score of the patients determined before starting hemodialysis treatment was 0 in 31 (18%), 1 in 45 (26%), 2 in 61 (35%), 3 in 33 (19%), 4 in 2 (1%) patients. Nutritonal status of the patients which was grouped according to the serum albumin levels were as follows: 52 patients were well-nourished (alb>3.5 mg/dl), 22 patients were fairly well-nourished (alb=3.0-3.5 mg/dl) and 15 patients were poorly nourished (alb<3.0 mg/dl). According to the co-morbidity status of the patients; 46 patients had no co-morbidities, 108 patients had cardiovascular morbidity, 5 patients had co morbidities related to central nervous system, 2 patients related to peripheral vascular system, 4 patients had neoplastic diseases, another 4 had tuberculosis and 5 patients had miscellanous co-morbidities. 17 patients had 2 co-morbidities and 3 patients had 3 co-morbidities together. The patients who had cardiovascular morbidities; 98 of them had hypertension, 40 of them had ischemic heart disease, 37 of them had congestive heart failure, 23 of them had any 2 of these morbidities and finally 3 of them had any 3 of these morbidities. The mean arterial blood pressures of the patients were as follows: Predialysis systolic37 blood pressure (SBP) 144.95mmHg, predialysis diastolic blood pressure (DBP) 86.95mmHg, predialysis mean arterial blood pressure (MAP) 106.34mmHg, postdialysis SBP 142.16mmHg, postdialysis DBP 86.95mmHg, postdialysis MAP 102.05mmHg. 61 of the 172 (%35) patients were using anti-hypertensive drugs. There were records of 69 patients concerning hepatic serology; 25 of the patients were HbsAg (+), 13 of the patients were anti- HbsAg (+), 31 of the patients were anti-HCV (+). Some of the laboratory values of the patients were as follows: The mean hematocrit level was 27.8%, the mean serum albumin level was 3.1 g/dl, the mean total cholesterol level was 97.26 mg/dl, the mean LDL level was 53.14 mg/dl, the mean predialysis urea level was 210.22 mg/dl, the mean postdialysis urea level was 97.75 mg/dl, the mean creatinine level was 6.6 mg/dl. The mean Kt/V values of all of the patients was 1.1 /day; of the patients who underwent hemodialysis therapy twice weekly was i 'day; of the patients who underwent hemodialysis therapy thrice weekly was 1.1 /day. The mean URR values of the patients was 56%. The 5 and 10 year survivals of the patients determined by using Kaplan-Meier method was 42% and 25.3% respectively. By this method the patients who were transplanted, who passed to CAPD program or who went to another hemodialysis centre were all censored. By performing Sel wood method the 5 and 10 year survivals of the patients were found to be 46.2% and 32.2% respectively. This method also takes into account the patients who were transplanted, the patients who went to CAPD, the patients who went to other hemodialysis centres. The 5 year survivals of the patients who underwent hemodialysis treatment thrice weekly (%43.2) was better than the ones who underwent the hemodialysis tretment twice weekly (%41.8) but the difference was statistically insignificant according to the log- rank method. Cox Regression Hazard model was performed to find out the factors which had affected the survivals of the patients. The statistically significant factors were found as follows: the mean albumin level (p=0.001), the mean hematocrit level (p=0.001), the mean postdialysis38 diastolic blood pressure (p=0.01), the mean creatinine level (p=0.01), the mean age (p=0.02), Karnofsky performans skor (p=0.02), the mean predialysis diastolic blood pressure (p=0.02), cardiovascular system morbidity (p=0.03), the mean predialysis blood pressure (MAP) (p=0.05), the mean Kt/V (p=0.05). Sex, weight, cigarette smoking, cooperation, predialysis systolic blood pressure, postdialysis both systolic and diastolic blood pressure, co-morbidities other than cardiovascular morbidity were found to be statistically insignificant factors affecting the survival.
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