Rationale & Objective

Concerns about nonadherent behaviors often prevent dialysis patients from entering waitlists for transplant even though there is an inconsistent association of these behaviors with posttransplant outcomes. We examined the association between plausible metrics of nonadherence related to dialysis treatment and posttransplant outcomes.

Study Design

Retrospective cohort. We linked national dialysis treatment data with transplant registry data.

Setting and Participants

Adult patients receiving maintenance hemodialysis from January 1, 2004, through December 31, 2014, who received a kidney transplant at a US center.

Exposures

We examined 5 nonadherence metrics: serum potassium level (≥5.2 mEq/L), serum phosphorus level (>5.5 mg/dL), interdialytic weight gain (IDWG; ≥5 L), shortened treatments (≥30 min), and missed treatments (≥1); missed treatment data were available only for 2004-2009. These metrics were characterized per proportion of time under observation. Dialysis observation time was divided into 3-month intervals (quarters), and the number of nonadherent measurements in each domain was calculated for each quarter.

Outcomes

Allograft loss, mortality, and acute rejection in the first posttransplant year.

Analytical Approach

Using Cox proportional hazards and logistic regression, we estimated the hazard ratios for graft loss and mortality and odds ratios for rejection.

Results

9,543 patients met inclusion criteria. In our primary model, hyperphosphatemia (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.08-1.49]), large IDWG (aHR, 1.39 [95% CI, 1.23-1.59]), and shortened treatments (aHR, 1.54 [95% CI, 1.12-2.13]) were associated with greater rates of allograft loss, but hyperkalemia was not. Large IDWG (aHR, 1.49 [95% CI, 1.29-1.73]) and shortened treatments (aHR, 1.34 [95% CI, 1.13-1.58]) were associated with mortality, whereas hyperkalemia and hyperphosphatemia were not. Only shortened treatments were associated with an increased risk of acute rejection (adjusted odds ratio, 3.88 [95% CI, 1.98-7.58]). In models limited to the years 2004-2009 that included missed treatments, missed treatments were associated only with mortality.

Limitations

Unmeasured confounding (eg, dietary data); adherence metrics used may have multiple, complex causes.

Conclusions

Plausible measures of dialysis nonadherence have long-term associations with allograft and patient survival. Behavioral metrics were more closely associated with outcomes than laboratory markers were. The implications of nonadherent behaviors for dialysis patients must be carefully considered before patients are excluded from transplantation.

中文翻译：

---

透析不依从性与肾移植结果：回顾性队列研究

理由和目标

对不依从行为的担忧通常会阻止透析患者进入移植等待名单，尽管这些行为与移植后结果的关联不一致。我们检查了与透析治疗相关的不依从性的合理指标与移植后结果之间的关联。

学习规划

回顾性队列。我们将国家透析治疗数据与移植登记数据联系起来。

背景及参与者

2004年1月1日至2014年12月31日期间接受维持性血液透析并在美国中心接受肾移植的成年患者。

曝光

我们检查了 5 个不依从性指标：血清钾水平 (≥5.2 mEq/L)、血清磷水平 (>5.5 mg/dL)、透析间期体重增加 (IDWG；≥5 L)、缩短治疗时间（≥30 分钟）和错过治疗(≥1)；仅提供 2004-2009 年错过的治疗数据。这些指标按照观察时间的比例进行表征。透析观察时间分为 3 个月的间隔（季度），并计算每个季度每个领域中不依从测量的数量。

结果

移植后第一年的同种异体移植损失、死亡率和急性排斥反应。

分析法

使用 Cox 比例风险和逻辑回归，我们估计了移植物丢失和死亡率的风险比以及排斥反应的比值比。

结果

9,543 名患者符合纳入标准。在我们的主要模型中，高磷血症（调整后的风险比 [aHR]，1.27 [95% CI，1.08-1.49]）、大 IDWG（aHR，1.39 [95% CI，1.23-1.59]）和缩短治疗时间（aHR，1.54） [95% CI, 1.12-2.13]）与较高的同种异体移植物丢失率相关，但高钾血症则不然。大 IDWG（aHR，1.49 [95% CI，1.29-1.73]）和缩短治疗时间（aHR，1.34 [95% CI，1.13-1.58]）与死亡率相关，而高钾血症和高磷血症则不然。只有缩短治疗时间才会增加急性排斥反应的风险（调整后的比值比，3.88 [95% CI，1.98-7.58]）。在仅限于 2004-2009 年（包含错过治疗）的模型中，错过治疗仅与死亡率相关。

局限性

未测量的混杂因素（例如饮食数据）；使用的依从性指标可能有多种复杂的原因。

结论

透析不依从性的合理测量与同种异体移植物和患者生存具有长期关联。行为指标比实验室指标与结果的关系更为密切。在将患者排除在移植之前，必须仔细考虑不依从行为对透析患者的影响。