Kausz Annamaria T, Obrador Gregorio T, Arora Pradeep, Ruthazer Robin, Levey Andrew S, Pereira Brian J G
Division of Nephrology, New England Medical Center, Boston, Massachusetts.
Panamerican University School of Medicine, Mexico City, Mexico.
J Am Soc Nephrol. 2000 Dec;11(12):2351-2357. doi: 10.1681/ASN.V11122351.
The ideal timing of initiation of renal replacement (RRT) therapy has been debated. It is currently recommended that RRT be instituted once the GFR falls below 10.5 ml/min per 1.73 m(2), unless edema-free body weight is stable or increased, the normalized protein nitrogen appearance rate is 0.8 g/kg per d or greater, and there are no clinical signs or symptoms of uremia. However, the mean estimated GFR at initiation of dialysis in the United States is 7.1 ml/min per 1.73 m(2). Factors that are associated with timing of initiation of dialysis in the United States are not clear. A cross-sectional study was performed to determine the factors that are associated with late initiation of dialysis as defined by GFR at initiation of less than 5 ml/min per 1.73 m(2) among patients who began dialysis in the United States between 1995 and 1997. Data were obtained from the U.S. Renal Data System, and GFR was estimated using the formula derived from the Modification of Diet in Renal Disease Study. Twenty-three percent of patients started dialysis late. In the multivariate analysis, women (odds ratio [OR] = 1.70), Hispanics and Asians (OR = 1.47 and 1.66, respectively, compared with Caucasians), uninsured patients (OR = 1.55 compared with private insurance), and employed patients (OR = 1.20) were more likely to start dialysis late. Patients with diabetes, cardiac disease, peripheral vascular disease, and poor functional status were less likely to start dialysis late compared with patients without these comorbid conditions. Certain nonclinical patient characteristics, notably female gender, race, and lack of insurance, are related to an increased likelihood of late initiation of dialysis. These factors may reflect reduced access to care. Additional studies are indicated to determine the potential impact of reduced access to care and whether late initiation of dialysis results in adverse clinical and economic outcomes among patients with end-stage renal disease in the United States.
肾脏替代治疗（RRT）开始的理想时机一直存在争议。目前建议，一旦肾小球滤过率（GFR）降至每1.73平方米低于10.5毫升/分钟，就应开始RRT治疗，除非无水肿体重稳定或增加、标准化蛋白氮出现率为每日每千克0.8克或更高，且没有尿毒症的临床体征或症状。然而，在美国，开始透析时的平均估计GFR为每1.73平方米7.1毫升/分钟。在美国，与透析开始时机相关的因素尚不清楚。进行了一项横断面研究，以确定在1995年至1997年期间在美国开始透析的患者中，与透析开始较晚（定义为开始时GFR低于每1.73平方米5毫升/分钟）相关的因素。数据来自美国肾脏数据系统，GFR使用源自肾脏疾病饮食改良研究的公式进行估计。23%的患者开始透析较晚。在多变量分析中，女性（优势比[OR]=1.70）、西班牙裔和亚裔（与白种人相比，OR分别为1.47和1.66）、未参保患者（与私人保险相比，OR=1.55）以及就业患者（OR=1.20）更有可能开始透析较晚。与没有这些合并症的患者相比，患有糖尿病、心脏病、外周血管疾病和功能状态较差的患者开始透析较晚的可能性较小。某些非临床患者特征，尤其是女性性别、种族和缺乏保险，与透析开始较晚的可能性增加有关。这些因素可能反映了获得医疗服务的机会减少。需要进行更多研究，以确定获得医疗服务机会减少的潜在影响，以及在美国终末期肾病患者中，透析开始较晚是否会导致不良的临床和经济后果。
