The timing of specialist evaluation in chronic kidney disease and mortality
The timing of specialist evaluation in chronic kidney disease and mortality
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DOI：
10.7326/0003-4819-137-6-200209170-00007
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发表时间：
2002-09-17
影响因子：
39.2
通讯作者：
Powe, NR
中科院分区：
文献类型：
--
作者：
Kinchen, KS;Sadler, J;Powe, NR
背景：慢性肾衰竭的治疗包括并发症的处理以及为可能进行的透析做准备。患者往往不能及时得到肾病专家的评估。
目的：确定与肾病专家延迟评估相关的因素，并评估一旦患者发展为终末期肾病（ESRD），延迟评估是否与更差的生存率相关。
设计：全国前瞻性队列研究。
地点：美国各地的81个透析机构。
患者：828名新发ESRD患者。
测量指标：从肾病专家首次评估到开始透析的时间，分为延迟（≥12个月）；从开始透析到平均2.2年随访期间的死亡率；以及人口统计学、临床和实验室特征。
结果：在对潜在混杂因素进行调整后，黑人男性比白人男性更常出现延迟评估（44.8%对24.5%；P<0.05），未参保患者比参保患者更常出现延迟评估（56.7%对29.0%；P<0.05），患有严重合并症的患者比患有轻度合并症的患者更常出现延迟评估（35.0%对23.0%；P<0.05）。与早期评估的患者相比，延迟评估的患者死亡风险更高，并且在对透析方法、人口统计学特征和社会经济状况进行Cox比例风险回归分析调整后，呈现出分级情况（中度评估患者的风险比为1.3[95%置信区间，0.87 - 2.06]，延迟评估患者为1.8[置信区间，1.21 - 2.61]）。在对合并症的存在和严重程度等因素进一步调整后，这种相关性仍然呈现分级情况（中度评估患者的风险比为1.2[置信区间，0.73 - 1.82]，延迟评估患者为1.6[置信区间，1.04 - 2.39]）。
结论：肾病专家对慢性肾衰竭患者的延迟评估与合并症的更大负担和严重程度、黑人种族、缺乏医疗保险以及更短的生存期相关。
Background: Care for chronic renal failure involves management of complications and preparation for possible dialysis. Patients often are not evaluated by nephrologists in a timely manner.Objective: To identify factors associated with late evaluation by a nephrologist and to assess whether late evaluation is associated with worse survival once patients develop end-stage renal disease (ESRD).Design: National prospective cohort study.Setting: 81 dialysis facilities throughout the United States.Patients: 828 patients with new-onset ESRD.Measurements: Time from first evaluation by a nephrologist to initiation of dialysis, classified as late (12 months); rate of death, from initiation of dialysis to an average of 2.2 years of follow-up; and demographic, clinical, and laboratory characteristics.Results: After adjustment for potential confounders, late evaluation was more common among black men than white men (44.8% vs. 24.5%; P < 0.05), uninsured patients than insured patients (56.7% vs. 29.0%; P < 0.05) and patients with severe comorbid disease than those with mild comorbid disease (35.0% vs. 23.0%; P < 0.05). Compared with patients who had early evaluation, the risk for death was greater among patients evaluated late and was graded (hazard ratio, 1.3 [95% CI, 0.87 to 2.06] for patients with intermediate evaluation and 1.8 [CI, 1.21 to 2.61] for those with late evaluation) after adjustment for dialysis method, demographic characteristics, and socioeconomic status in Cox proportional hazards regression analysis. After additional adjustment for such factors as the presence and severity of comorbid conditions, the association remained graded (hazard ratio, 1.2 [CI, 0.73 to 1.82] for patients evaluated at an intermediate point and 1.6 [CI, 1.04 to 2.39] for those evaluated late).Conclusions: Late evaluation of patients with chronic renal failure by a nephrologist is associated with greater burden and severity of comorbid disease, black ethnicity, lack of health insurance, and shorter duration of survival.