Lhotta Karl, Zoebl Michael, Mayer Gert, Kronenberg Florian
Division of Nephrology, Department of Internal Medicine, Innsbruck University Hospital, Innsbruck, Austria.
J Nephrol. 2003 Nov-Dec;16(6):855-61.
Many patients with chronic renal failure are referred very late to nephrology units. Late referral (LR) is reported to be associated with increased morbidity and mortality.
We used glomerular filtration rate (GFR) at the first visit to a nephrologist to define early referral (ER) and LR in a retrospective analysis. Patients admitted with a GFR < 20 mL/min/1.73 m2 were classified as LR. The 75 patients with chronic renal failure beginning renal replacement therapy (RRT) at Innsbruck University Hospital between January 1999 and October 2000 were included. Patient characteristics were compared between the two groups. Survival analysis until the end of 2002 was carried out using Cox's proportional hazard model. To identify the influence of comorbidity on mortality a comorbidity score was applied.
Thirty-three patients were classified as ER and 42 patients as LR. Diabetic nephropathy was more frequent in the LR group (18 vs. 6 patients, p = 0.005). ER patients were significantly younger (53 +/- 16 yrs) as compared to LR patients (62 +/- 14 yrs, p = 0.012). Comorbid conditions were more frequent in the LR group (comorbidity score 1.5 +/- 1.3 for LR and 0.7 +/- 1.1 for ER, p = 0.003). During follow-up, 27 patients died, 19 from the LR group and 8 from the ER group. In the univariate analysis, comorbidity score (p < 0.001) and age (p = 0.017) were significantly associated with mortality, whereas LR patients demonstrated higher mortality (p = 0.076). By multivariate analysis the comorbidity score (p < 0.001) only was associated with mortality within at least 2 yrs of RRT.
Over half of the patients with end-stage renal disease (ESRD) were referred too late, with a GFR < 20 mL/min/1.73 m2. Mortality during the 1st 2 yrs on RRT was mainly determined by comorbidity, acquired during the course of chronic renal failure. In comparison, the negative impact of LR seems to be minor and requires a larger sample size to be demonstrated.
许多慢性肾衰竭患者很晚才被转诊至肾脏病科。据报道，延迟转诊（LR）与发病率和死亡率增加相关。
在一项回顾性分析中，我们使用首次就诊于肾脏病专家时的肾小球滤过率（GFR）来定义早期转诊（ER）和LR。GFR＜20 mL/（min·1.73 m²）的入院患者被归类为LR。纳入了1999年1月至2000年10月期间在因斯布鲁克大学医院开始肾脏替代治疗（RRT）的75例慢性肾衰竭患者。比较了两组患者的特征。使用Cox比例风险模型进行至2002年底的生存分析。为确定合并症对死亡率的影响，应用了合并症评分。
33例患者被归类为ER，42例患者被归类为LR。LR组糖尿病肾病更为常见（18例对6例，p = 0.005）。与LR患者（62±14岁，p = 0.012）相比，ER患者明显更年轻（53±16岁）。LR组合并症更常见（LR组合并症评分为1.5±1.3，ER组为0.7±1.1，p = 0.003）。随访期间，27例患者死亡，LR组19例，ER组8例。单因素分析中，合并症评分（p＜0.001）和年龄（p = 0.017）与死亡率显著相关，而LR患者死亡率更高（p = 0.076）。多因素分析显示，仅合并症评分（p＜0.001）与RRT至少2年内的死亡率相关。
超过半数的终末期肾病（ESRD）患者转诊过晚，GFR＜20 mL/（min·1.73 m²）。RRT开始后前2年的死亡率主要由慢性肾衰竭病程中获得的合并症决定。相比之下，LR的负面影响似乎较小，需要更大样本量才能证实。
