| Abstract | Odluka o odabiru vrste dijalize kojom će započeti liječenje pacijenta u posljednjoj fazi
bubrežne bolesti često je kompleksna i pod utjecajem brojnih čimbenika. Svrha ovog
istraživanja bila je ustanoviti upalno opterećenje koje parodontitis može predstavljati kod
pacijenata na dijalizi, usporediti parodontni status onih na hemodijalizi i onih na peritonejskoj
dijalizi i na taj način eventualno olakšati izbor modaliteta dijalize.
U istraživanju je sudjelovalo 89 pacijenata koji su liječeni hemodijalizom odnosno
peritonejskom dijalizom. Uz uobičajene parodontne indekse izračunata je i površina
parodonta zahvaćena upalom (PISA) na temelju kliničkog gubitka pričvrstka (CAL), recesija
gingive (REC) i krvarenja na sondiranje (BOP). Uz ispunjavanje ankete o osnovnim
sociodemografskim podacima i navikama pacijenata korišteni su i laboratorijski podaci koji se
uobičajeno prate kod pacijenata na dijalizi a iz kartona pacijenata izvađeni su sljedeći podatci:
osnovna bubrežna bolest, postojanje dijabetesa, duljina trajanja dijabetesa, indeks tjelesne
mase (BMI), postojanje arterijske hipertenzije, diureza, lijekovi koje pacijent uzima i
normalizirani terapijski omjer (Kt/V).
Istraživanjem je pokazano da se svi parodontološki indeksi značajno razlikuju s obzirom na
tip dijalize, pri čemu pacijenti na hemodijalizi imaju više rezultate nego oni na peritonejskoj.
Učinak tipa dijalize na razlike u indeksima kreće se od slabog do umjerenog (0,24 - 0,59).
Gotovo svi parodontološki indeksi međusobno su značajno te umjereno do jako povezani, uz
djelomičnu iznimku recesije gingive. Dob i broj zuba značajno su povezani s većim brojem
pardonotoloških indeksa. Od laboratorijskih pokazatelja, veći broj značajnih povezanosti
ustanovljen je za Kt/V, parotiroidni hormon, trombocite, leukocite i ureu. Pacijenti na
peritonejskoj dijalizi imali su 746 mm² (93%) niži srednji PISA indeks nego pacijenti na
hemodijalizi nakon prilagodbe na 20 zbunitelja. Nakon prilagodbe na zbunitelje nije bila
značajna korelacija između trajanja i tipa dijalize (F (2,44)=0.01; p=0.994;. η2=0.00).
Rezultati ovog istraživanja pokazali su da su pacijenti na hemodijalizi u visokoj potrebi za
parodontološkim liječenjem te da imaju lošiji parodontni status od pacijenata na peritonejskoj
dijalizi neovisno o brojnim sociodemografskim, laboratorijskim i kliničkim čimbenicima.
Potrebna su prospektivna, randomizirana kontrolirana istraživanja kako bi se ustanovila
uzročna povezanost |
| Abstract (english) | Background:
Chronic kidney disease (CKD) is progressive and characterised by the destruction of
nephrons. The loss of kidney functions leads to the accumulation of metabolic waste
products that have an impact on the patient’s body. There are five CKD stages according to
the estimated glomerular filtration rate (eGFR), and the last stage is end-stage renal disease
(ESRD) or kidney failure (eGFR < 15 ml/min/1.73 m). The treatment of CKD consists of
conservative therapy aiming at slowing down the progression of the disease. However,
when these measures are insufficient, the patient undergoes dialysis or a transplantation is
performed. A kidney transplantation is the treatment of choice for improved survival of
ESRD patients, but when a transplantation is not possible either due to the medical
condition of the patient or the lack of available organs, dialysis is a viable treatment option.
There are two main types of dialysis: haemodialysis (HD) and peritoneal dialysis (PD). The
decision to initiate dialysis treatment using either haemodialysis or peritoneal dialysis is
often complex and remains open to debate. Although PD has proven to provide similar or
better survival rates and a better quality of life in addition to PD being more economical
than HD, in 2008, there were only 196 000 PD patients comprising 11% of the global
dialysis population.
Periodontitis is a bacteria-driven chronic inflammatory disease that destroys the connective
tissue and bone supporting the teeth. Periodontitis represents a potential source of episodes
of bacteraemia, especially in immunocompromised patients. Its impact on the general health
status is becoming increasingly apparent. A recent meta-analysis confirmed that there is a
link between CKD and periodontal disease. Periodontitis thus represents an often
overlooked problem in CKD patients. The lack of oral health management may contribute to
systemic consequences, such as inflammation, infection, protein-energy wasting and
atherosclerotic complications, which can contribute to increased morbidity and mortality.
The aim of this study was to quantify the inflammatory burden that periodontitis poses in
dialysis patients and to examine whether PD and HD patients differ according to their
periodontal status, which can be helpful in selecting the most appropriate type of dialysis.
The main hypothesis put forth in this study is that PD patients have a better periodontal
status than HD patients.
Methods: A cross-sectional study including 58 consecutive HD patients and 31 consecutive
PD patients was conducted. In addition to the usual periodontal indices, the periodontal
inflamed surface area (PISA) was calculated based on bleeding on probing (BOP), clinical
attachment level (CAL) and gingival recession (REC) measurements that were performed at
six sites on each tooth using a periodontal probe (PCP 15; Hu-Friedy, Chicago, IL, USA). All
periodontal examinations were performed by the same calibrated examiner. Based on existing
literature and previous studies, before conducting our analysis, 15 variables were selected
with possible confounding effects: age, duration of dialysis in months, number of teeth,
smoking habits, C-reactive protein, dialysis adequacy measured by the ratio between dialyser
clearance (K) (mL/min) multiplied by time in minutes (t) and the volume of water a patient’s
body contains (Kt/V), thrombocytes, urea, phosphorus, high-density lipoprotein (HDL)
cholesterol and treatment with beta-blockers, angiotensin-converting enzyme inhibitors,
central α-2 receptor agents, angiotensin II AT1-receptor blockers, and α₁-adrenoceptor
antagonists. We also controlled five additional possible confounders: diabetes mellitus,
duration of diabetes, glycated haemoglobin (HbA1c), leukocytes, and the last visit to the
dentist.
Information about age, gender, education, smoking habits and consumption of alcohol,
xerostomia, self-observed bleeding of gums and oral hygiene habits was obtained through a
questionnaire that was designed specifically for this study.
Results: After screening 127 patients, 89 were enrolled, 58 of whom were undergoing HD
and 31 of whom were undergoing PD. The two groups were different with regard to many
sociodemographic, vital, lifestyle and clinical characteristics. HD patients were older, had
been undergoing dialysis longer, had fewer teeth, and had less self-reported bleeding of the
gums. According to blood count, the largest differences were in Kt/V and parathyroid
hormone levels. Kt/V was higher in the PD group and the parathyroid hormone was higher in
the HD group. There were also relevant differences in C-reactive protein values (higher in the
HD group) and in thrombocyte values (higher in the PD group). All periodontal indices were
significantly different according to the type of dialysis; haemodialysis patients had higher
scores than peritoneal dialysis patients. In the introductory bivariable analysis, PISA was
significantly different between the two dialysis groups. The mean PISA (SD) was 738 (520.4)
mm2 in HD patients and 470 (277.8) mm2 in PD patients. After adjusting for 20
confounding factors, the type of dialysis was found to be significantly associated
(FDR<5%) with PISA. PD patients had a significantly lower PISA. After adjusting for 20
confounding factors, the mean (95% CI) PISA was 798 (681-914) mm2 in the HD group and
52 (0-417) mm2 in the PD group. This 746 mm2 absolute difference represented a 93%
relative difference. The adjusted median PISA was 732 mm2 in the HD group and 190
mm2 in the PD group. This 542 mm2 absolute difference represented a 74% relative
difference. The type of dialysis showed a semipartial correlation with PISA (sr=-0.50,
p<0.017; FDR<5%). The variation in HbA1c values imputed for patients with no diagnosed
diabetes mellitus 4, 5 and 7 revealed identical results. A sensitivity analysis was performed
by multiple imputation of the missing data of 20 confounding factors. A pooled analysis on
30 data sets with complete (imputed) data revealed very similar results to the result of the
per-protocol and complete case (listwise deletion) analyses: PD patients had a mean (95%
CI) PISA of -613 (-995 to -232); robust regression, ( p=0.002) and a median (95% CI) PISA
of -448 (-887 to -9; quantile regression, p=0.046). PISA was significantly lower in the PD
group regardless of the duration of dialysis. After adjusting for confounding factors, the
interaction between the duration and type of dialysis was not significant (F (2,44)=0.01;
p=0.994; η2=0.00). The differences in PISA between patients who had been dialysed for less
than a year, 2-3 years or ≥3 years were not significantly different in any of the two dialysis
groups.
Conclusions: Patients undergoing dialysis have poor periodontal conditions and require
periodontal treatment. PD is associated with a lower PISA and other periodontal indices
regardless of many sociodemographic, lifestyle, laboratory and clinical factors. A prospective, randomised control study is needed to test for a causal relationship. |
