vtioВестник трансплантологии и искусственных органовRussian Journal of Transplantology and Artificial Organs1995-1191Academician V.I.Shumakov National Medical Research Center of Transplantology and Artificial Organs", Ministry of Health of the Russian Federation10.15825/1995-1191-2018-2-47-60vtio-882Research ArticleТрансплантация сердца и вспомогательное кровообращениеHeart Transplantation and Assisted CirculationОПРЕДЕЛЕНИЕ СРОКОВ НАЧАЛА ГЕМОДИАЛИЗА: РАЗРАБОТКА И ПОДТВЕРЖДЕНИЕ ШКАЛЫ STARTDIALYSIS START TIMING: DEVELOPMENT AND VALIDATION OF START SCORING SCALEЗемченковА. Ю.ZemchenkovA. Yu.

191104, Россия, Санкт-Петербург, Литейный пр., 56.

191104, 56, Liteiny pr., Saint-Petersburg.

kletk@inbox.ruГерасимчукР. П.GerasimchukR. P.СабодашА. Б.SabodashA. B.ВишневскийК. А.VishnevskiiK. A.ЗемченковГ. А.ZemchenkovG. A.ОмельченкоА. М.OmelchenkoA. M.КулаеваН. Н.KulaevaN. N.КонаковаИ. Н.KonakovaI. N.ЯковенкоА. А.YakovenkoA. A.РумянцевА. Ш.RumyantsevA. Sh.СПбГБУЗ «Городская Мариинская больница» – Городской нефрологический центр; Северо-Западный государственный медицинский университет им. И.И. Мечникова; Первый Санкт-Петербургский государственный медицинский университет им. акад. И.П. Павлова.РоссияCity Mariinsky hospital; North-Western State medical university n.a. I.I. Mechnikov; First Saint-Petersburg State medical university n.a. I.P. Pavlov.Russian FederationСПбГБУЗ «Городская Мариинская больница» – Городской нефрологический центр; Северо-Западный государственный медицинский университет им. И.И. Мечникова.РоссияCity Mariinsky hospital; North-Western State medical university n.a. I.I. Mechnikov.Russian FederationПервый Санкт-Петербургский государственный медицинский университет им. акад. И.П. Павлова; ББраун Авитум Руссланд Клиникс.РоссияFirst Saint-Petersburg State medical university n.a. I.P. Pavlov; BBraun Avitum Russland Clinic.Russian FederationСПбГБУЗ «Городская больница № 15».РоссияCity hospital 15.Russian FederationББраун Авитум Руссланд Клиникс.РоссияBBraun Avitum Russland Clinic.Russian FederationСПбГБУЗ «Городская Мариинская больница» – Городской нефрологический центр.РоссияCity Mariinsky hospital.Russian FederationСеверо-Западный государственный медицинский университет им. И.И. Мечникова.РоссияNorth-Western State medical university n.a. I.I. Mechnikov.Russian FederationПервый Санкт-Петербургский государственный медицинский университет им. акад. И.П. Павлова.РоссияFirst Saint-Petersburg State medical university n.a. I.P. Pavlov.Russian FederationПервый Санкт-Петербургский государственный медицинский университет им. акад. И.П. Павлова; Санкт-Петербургский государственный университет.РоссияSaint-Petersburg State university.Russian Federation2018260620182024760Copyright © Земченков А.Ю., Герасимчук Р.П., Сабодаш А.Б., Вишневский К.А., Земченков Г.А., Омельченко А.М., Кулаева Н.Н., Конакова И.Н., Яковенко А.А., Румянцев А.Ш., 20182018Земченков А.Ю., Герасимчук Р.П., Сабодаш А.Б., Вишневский К.А., Земченков Г.А., Омельченко А.М., Кулаева Н.Н., Конакова И.Н., Яковенко А.А., Румянцев А.Ш.Zemchenkov A.Y., Gerasimchuk R.P., Sabodash A.B., Vishnevskii K.A., Zemchenkov G.A., Omelchenko A.M., Kulaeva N.N., Konakova I.N., Yakovenko A.A., Rumyantsev A.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.transpl.ru/vtio/article/view/882Цель

Цель. Оптимальное время начала лечения гемодиализом (ГД) остается неопределенным. Создание шкалы для оценки рисков для пациента, начинающего диализ, поможет в принятии решения о сроках его начала.

Методы

Методы. По данным регистра пациентов на заместительной почечной терапии проанализированы результаты лечения 1856 пациентов, начавших диализ в 2009–2016 гг. Случайным образом их разделили в соотношении 1:1 на группу разработки и группу подтверждения для создания прогностической шкалы оценки вероятности летального исхода при лечении программным гемодиализом (шкала START). При этом учитывали модифицируемые и немодифицируемые факторы риска. В серии регрессионных моделей с одной переменной в группе разработки шкалы мы оценивали риски смерти, связанные с доступными для анализа модифицируемыми и немодифицируемыми параметрами. Среди них значимыми оказались возраст, расчетная скорость клубочковой фильтрации (рСКФ), уровни фосфатов, общего кальция, гемоглобина, индекс коморбидности Чарлсон, наличие сахарного диабета, экстренность старта диализа. Пол, уровни натрия, калия, артериального давления не оказали влияния на выживаемость. Близкие по величине риски были преобразованы в баллы шкалы.

Результаты

Результаты. Шкала START продемонстрировала высокую предсказательную ценность в отношении риска смерти: AUC 0,82 (95% ДИ 0,79–0,85) для группы разработки шкалы и 0,79 (95% ДИ 0,74–0,84) для группы подтверждения (для обеих p < 0,001). Для точки отсечения 7–8 баллов чувствительность метода составила 81,1%, специфичность 69,9% для группы разработки и 78,9 и 67,9% соответственно – для группы подтверждения. Мы подтвердили близкие значения выживаемости пациентов в обеих группах для низких, средних и высоких значений шкалы START. Различия в выживаемости для подгрупп с тремя уровнями шкалы были близкими для групп разработки и подтверждения: критерий Wilcoxon = 8,78 (p = 0,02) vs 15,31 (p < 0,001) при сравнении выживаемости подгрупп низких и средних величин шкалы и 25,18 (p < 0,001) vs 39,21 (p < 0,001) при сравнении выживаемости подгрупп средних и высоких величин шкалы.

Заключение

Заключение. Разработанная шкала START, включающая модифицируемые факторы риска, продемонстрировала хорошую предсказательную ценность в отношении 5-летней летальности и может использоваться при принятии решения о времени старта диализа. 

Aim

Aim. The optimal time for initiating of chronic dialysis remains unknown. The scale for mortality risk assessment could help in decision-making concerning dialysis start timing.

Methods

Methods. We randomly divided 1856 patients started dialysis in 2009–2016 into developmental and validation group (1:1) to create and validate scoring system «START» predicting mortality risk at dialysis initiation in order to fi nd unmodifi able and modifi able factors which could help in the decision-making of dialysis start. In the series of univariate regression models in the developmental set, we evaluated the mortality risk linked with available parameters: age, eGFR, serum phosphate, total calcium, hemoglobin, Charlson comorbidity index, diabetes status, urgency of start (turned to be signifi cant) and gender, serum sodium, potassium, blood pressure (without impact on survival). Similar hazard ratios were converted to score points.

Results

Results. The START score was highly predictive of death: C-statistic was 0.82 (95% CI 0.79–0.85) for the developmental dataset and 0.79 (95% CI 0.74–0.84) for validation dataset (both p < 0.001). On applying the cutoff between 7–8 points in the developmental dataset, the risk score was highly sensitive 81.1% and specifi c 67.9%; for validation dataset, the sensitivity was 78.9%, specifi city 67.9%. We confi rmed the similarity in survival prediction in the validation set to developmental set in low, medium and high START score groups. The difference in survival between three levels of START-score in validation set remained similar to that of developmental set: Wilcoxon = 8.78 (p = 0.02) vs 15.31 (p < 0.001) comparing low–medium levels and 25.18 (p < 0.001) vs 39.21 (p < 0.001) comparing medium–high levels.

Conclusion

Conclusion. Developed START score system including modifi able factors showed good mortality prediction and could be used in dialysis start decision-making. 

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The authors declare that there are no conflicts of interest present.