Kessler Michèle, Frimat Luc, Panescu Victor, Briançon Serge
Department of Nephrology and the Department of Clinical Epidemiology and Evaluation, University Hospital of Nancy, Nancy, France.
Am J Kidney Dis. 2003 Sep;42(3):474-85. doi: 10.1016/s0272-6386(03)00805-9.
Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive.
Five hundred and two adult French patients (age, 62.8 +/- 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 micromol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression.
Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR < or = 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR < or = 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR < or = 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR < or = 1 month; CRF < or = 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis.
Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.
大多数关于终末期肾病（ESRD）的预后如何受到开始肾脏替代治疗（RRT）前接受治疗的时机和质量影响的研究尚无定论。
502例接受首次RRT的法国成年患者（年龄62.8±16岁）纳入了一项为期2年的社区前瞻性研究。根据首次血清肌酐读数高于2mg/dL（177μmol/L）至开始RRT之间的时间，将受试者分为5组中的1组：慢性肾衰竭（CRF）、肾病转诊（NR）和RRT。采用多因素逻辑回归分析90天生存数据，使用Cox比例风险回归分析有关长期生存和列入肾移植等待名单的数据。
90天时总生存率为88%，1年时为77.2%，2年时为65.2%，3年时为54.2%。肾病转诊模式与年龄和收缩压相关，并可独立预测早期死亡。与第1组（NR＞12个月）相比，第2组（NR≤12个月或＞4个月）的比值比（95%置信区间）为2.7（1.2至6.3），第3组（NR≤4个月或＞1个月）为2.8（1.0至8.0），第4组（NR≤1个月；CRF＞1个月）为4.9（2.2至11.0），第5组（NR≤1个月；CRF≤1个月）为5.2（2.2至12.3）。90天幸存者中死亡的独立预测因素为年龄、有心力衰竭既往发作史的心脏病、血管疾病、舒张压降低和第3组转诊模式。年龄、糖尿病、血管疾病和非择期首次透析可预测未被列入肾移植等待名单。
肾病转诊延迟与早期死亡密切相关。急诊首次透析是未被列入移植等待名单的独立危险因素。在90天幸存者中，转诊模式对死亡率影响不大，死亡率主要由开始RRT时的心血管并发症决定。
