When to refer patients with chronic kidney disease for vascular access surgery: Should age be a consideration?
When to refer patients with chronic kidney disease for vascular access surgery: Should age be a consideration?
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DOI：
10.1038/sj.ki.5002078
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发表时间：
2007-03-01
影响因子：
19.6
通讯作者：
Allon, M.
中科院分区：
文献类型：
--
作者：
O'Hare, A. M.;Bertenthal, D.;Allon, M.
为了确定年龄是否应该影响我们在慢性肾脏疾病患者中放置永久性血管通路的方法，我们对11 290名非透析患者进行了一项回溯性队列研究，根据退伍军人事务部2000-2001年的门诊肌酐测量，估计肾小球滤过率(EGFR)和25ml/min/1.73m(2)。对于每个年龄组，我们检查了进入队列后1年已经和没有获得永久接入的患者的百分比，以及每一组中死亡、开始透析或在没有透析的情况下存活的百分比。我们还根据现有的血管通路指南对理论场景中可能发生的不必要手术的数量进行了建模。队列进入时平均EGFR为17.7ml/min/1.73m(2)。25%(n=2870)的患者在进入队列后一年内开始透析。在这些人中，只有39%(n=1104)事先接受了手术以放置永久通道。与年轻患者相比，年龄较大的患者接受永久通路手术的可能性较小，但也不太可能开始透析。在所有接受检查的理论情景中，年龄较大的患者比年轻患者更有可能接受不必要的手术。如果所有患者在队列进入时都被转介接受永久通路手术，则在85-100岁的患者随访2年后，不必要的手术与必要的手术的比率将为5：1，而18-44岁的患者仅为0.5：1。目前为所有年龄的患者推荐的基于单一肾功能阈值水平的永久通路放置方法是不合适的。
To determine whether age should inform our approach toward permanent vascular access placement in patients with chronic kidney disease, we conducted a retrospective cohort study among 11 290 non-dialysis patients with an estimated glomerular filtration rate (eGFR) < 25 ml/min/ 1.73m(2) based on 2000 - 2001 outpatient creatinine measurements in the Department of Veterans Affairs. For each age group, we examined the percentage of patients that had and had not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis. We also modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines. The mean eGFR was 17.7 ml/min/1.73 m(2) at cohort entry. Twenty-five percent (n = 2870) of patients initiated dialysis within a year of cohort entry. Among these, only 39% (n = 1104) had undergone surgery to place a permanent access beforehand. As compared with younger patients, older patients were less likely to undergo permanent access surgery, but also less likely to start dialysis. In all theoretical scenarios examined, older patients would have been more likely than younger patients to receive unnecessary procedures. If all patients had been referred for permanent access surgery at cohort entry, the ratio of unnecessary to necessary procedures after 2 years of follow-up would have been 5:1 for patients aged 85 - 100 years but only 0.5:1 for those aged 18 - 44 years. Currently recommended approaches to permanent access placement based on a single threshold level of renal function for patients of all ages are not appropriate.