Ravani Pietro, Marinangeli Giancarlo, Tancredi Maurizio, Malberti Fabio
Nephrology and Dialysis Division, Cremona Hospital, Cremona, Italy.
J Nephrol. 2003 Nov-Dec;16(6):870-7.
Delayed nephrology referral is associated with increased morbidity and mortality after patients begin dialysis. However, whether a pre-dialysis educational program (PEP) confers any survival advantage in comparison to unstructured specialist care is not established.
Cox's regression analysis was used to estimate the association between the type of pre-dialysis follow-up and mortality in all consecutive end-stage renal disease (ESRD) adults starting dialysis therapy in two centers, between 1 January 1999 and 30 June 2002, and followed until 30 June 2003.
229 patients participated in the study. The patients tended to be male (62%), elderly (median age 70 yrs) and to have cardiovascular diseases (60%). Median follow-up on dialysis was 37.8 months, with 624 patient-yrs at risk and a 0.15 yr(-1) mortality rate. Patients receiving regular unstructured care (22.7%) appeared to have similar risk for death as late referrals (36.7%), while PEP patients (40.6%) showed longer survival (hazard ratio 0.48 (95% CI 0.27, 0.87)), allowing for demographics, comorbidities, duration of the pre-dialysis follow-up and dialysis modality. Planned dialysis commencement, a better metabolic status at dialysis initiation and the previous use of angiotensin converting enzyme inhibitors were the main factors associated with improved outcomes. The survival advantage associated with PEP was still present after late referrals or observation for < or = 1 yr were excluded, as well as when survival analysis was limited to the 1st year after dialysis initiation.
A multidisciplinary approach to chronic kidney diseases seems more effective than just timely referral to nephrologists in improving patient survival on dialysis.
肾病延迟转诊与患者开始透析后的发病率和死亡率增加相关。然而，与非结构化专科护理相比，透析前教育计划（PEP）是否具有任何生存优势尚未确定。
采用Cox回归分析来估计1999年1月1日至2002年6月30日期间在两个中心开始透析治疗并随访至2003年6月30日的所有连续性终末期肾病（ESRD）成年患者的透析前随访类型与死亡率之间的关联。
229名患者参与了研究。患者多为男性（62%），年龄较大（中位年龄70岁），且患有心血管疾病（60%）。透析的中位随访时间为37.8个月，有624患者年处于风险中，死亡率为0.15人年（-1）。接受常规非结构化护理的患者（22.7%）似乎与延迟转诊患者（36.7%）有相似的死亡风险，而PEP患者（40.6%）的生存期更长（风险比0.48（95%CI 0.27，0.87）），同时考虑了人口统计学、合并症、透析前随访时间和透析方式。计划开始透析、透析开始时更好的代谢状态以及先前使用血管紧张素转换酶抑制剂是与改善结局相关的主要因素。排除延迟转诊或观察时间≤1年的患者后，以及将生存分析限于透析开始后的第1年时，与PEP相关的生存优势仍然存在。
在提高透析患者生存率方面，慢性肾脏病的多学科方法似乎比单纯及时转诊至肾病科医生更有效。
