The Transition From the Pre-ESRD to ESRD Phase of CKD: Much Remains to Be Learned.
The Transition From the Pre-ESRD to ESRD Phase of CKD: Much Remains to Be Learned.
复制标题
CKD 从 ESRD 前期到 ESRD 阶段的转变：还有很多东西需要学习。
DOI：
10.1053/j.ajkd.2016.10.001
复制
发表时间：
2017
期刊：
影响因子：
--
通讯作者：
Hsu,Chi-Yuan
中科院分区：
文献类型：
--
作者：
Sharief,Shimi;Hsu,Chi-Yuan
Recently, there has been increasing interest in better understanding the transition from the pre–end-stage renal disease (ESRD) phase to the ESRD phase of chronic kidney disease (CKD), defined operationally as before and after initiation of long-term renal replacement therapy. For example, this transition is the focus of a new US Renal Data Systems (USRDS) Special Study, which published a chapter on “transition of care” in the 2015 USRDS Annual Data Report. 1 During this transition, patients are at a very vulnerable state and rates of adverse events are very high. It is also a period when nephrologists make many critical management decisions.Although a sizeable literature has been published regarding the association between timing of initiation of dialysis therapy and adverse outcomes, 2 less is known about the impact of reasons for initiation of dialysis therapy. In this issue of AJKD, Rivara et al3 add provocative new information to the field. The authors retrospectively reviewed the medical records of 461 patients who initiated maintenance dialysis (mostly hemodialysis) therapy in the Seattle region. During a median follow-up of 2.4 years, they observed 183 (40%) deaths. Rivara et al found that patients initiating dialysis therapy due to volume overload have increased risk for mortality compared with patients initiating dialysis therapy for all other reasons, even after adjusting for observed differences in patient characteristics (adjusted hazard ratio, 1.69; 95% confidence interval, 1.02–2.80). Those who initiated dialysis therapy primarily for uremic symptoms or for other/unknown reasons had similar risks compared with patients who initiated dialysis therapy primarily for laboratory evidence of kidney function decline (the reference group). Interestingly, this effect appeared to vary by subgroup: higher risk for death among those who initiated dialysis therapy due to volume overload was seen in the subset of patients who initiated dialysis therapy via a permanent vascular access, in those deemed to have nonurgent starts, and in those who initiated in an outpatient setting. However, this phenomenon was not observed in those who initiated dialysis therapy by a central venous catheter, those deemed to have urgent starts, and those who initiated in an inpatient setting. This study adds to the growing literature indicating that clinical events and medical management during the pre-ESRD phase of CKD have an important impact on outcomes after the onset of ESRD.
