Tonelli Marcello, Hemmelgarn Brenda, Manns Braden, Pylypchuk George, Bohm Clara, Yeates Karen, Gourishankar Sita, Gill John S
Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alta.
CMAJ. 2004 Sep 14;171(6):577-82. doi: 10.1503/cmaj.1031859.
Despite the increase in the number of Aboriginal people with end-stage renal disease around the world, little is known about their health outcomes when undergoing renal replacement therapy. We evaluated differences in survival and rate of renal transplantation among Aboriginal and white patients after initiation of dialysis.
Adult patients who were Aboriginal or white and who commenced dialysis in Alberta, Saskatchewan or Manitoba between Jan. 1, 1990, and Dec. 31, 2000, were recruited for the study and were followed until death, transplantation, loss to follow-up or the end of the study (Dec. 31, 2001). We used Cox proportional hazards models to examine the effect of race on patient survival and likelihood of transplant, with adjustment for potential confounders.
Of the 4333 adults who commenced dialysis during the study period, 15.8% were Aboriginal and 72.4% were white. Unadjusted rates of death per 1000 patient-years during the study period were 158 (95% confidence interval [CI] 144-176) for Aboriginal patients and 146 (95% CI 139-153) for white patients. When follow-up was censored at the time of transplantation, the age-adjusted risk of death after initiation of dialysis was significantly higher among Aboriginal patients than among white patients (hazard ratio [HR] 1.15, 95% CI 1.02-1.30). The greater risk of death associated with Aboriginal race was no longer observed after adjustment for diabetes mellitus and other comorbid conditions (adjusted HR 0.89, 95% CI 0.77-1.02) and did not appear to be associated with socioeconomic status. During the study period, unadjusted transplantation rates per 1000 patient-years were 62 (95% CI 52-75) for Aboriginal patients and 133 (95% CI 125-142) for white patients. Aboriginal patients were significantly less likely to receive a renal transplant after commencing dialysis, even after adjustment for potential confounders (HR 0.43, 95% CI 0.35-0.53). In an additional analysis that included follow-up after transplantation for those who received renal allografts, the age-adjusted risk of death associated with Aboriginal race (HR 1.36, 95% CI 1.21-1.52) was higher than when follow-up after transplantation was not considered, perhaps because of the lower rate of transplantation among Aboriginals.
Survival among dialysis patients was similar for Aboriginal and white patients after adjustment for comorbidity. However, despite universal access to health care, Aboriginal people had a significantly lower rate of renal transplantation, which might have adversely affected their survival when receiving renal replacement therapy.
尽管全球终末期肾病的原住民人数有所增加，但对于他们接受肾脏替代治疗后的健康结局却知之甚少。我们评估了原住民和白人患者开始透析后在生存及肾移植率方面的差异。
招募1990年1月1日至2000年12月31日期间在艾伯塔省、萨斯喀彻温省或曼尼托巴省开始透析的成年原住民或白人患者进行研究，并随访至死亡、移植、失访或研究结束（2001年12月31日）。我们使用Cox比例风险模型来检验种族对患者生存及移植可能性的影响，并对潜在混杂因素进行了调整。
在研究期间开始透析的4333名成年人中，15.8%为原住民，72.4%为白人。研究期间每1000患者年的未调整死亡率，原住民患者为158（95%置信区间[CI] 144 - 176），白人患者为146（95% CI 139 - 153）。当在移植时进行随访截尾时，透析开始后年龄调整后的死亡风险在原住民患者中显著高于白人患者（风险比[HR] 1.15，95% CI 1.02 - 1.30）。在对糖尿病和其他合并症进行调整后，与原住民种族相关的更高死亡风险不再明显（调整后HR 0.89，95% CI 0.77 - 1.02），且似乎与社会经济地位无关。在研究期间，每1000患者年的未调整移植率，原住民患者为62（95% CI 52 - 75），白人患者为133（95% CI 125 - 142）。即使在对潜在混杂因素进行调整后，原住民患者开始透析后接受肾移植的可能性仍显著较低（HR 0.43，95% CI 0.35 - 0.53）。在一项额外分析中，对于接受肾移植的患者纳入了移植后的随访，与原住民种族相关的年龄调整后的死亡风险（HR 1.36，95% CI 1.21 - 1.52）高于未考虑移植后随访时的情况，这可能是因为原住民的移植率较低。
在对合并症进行调整后，透析患者中原住民和白人患者的生存率相似。然而，尽管普遍可获得医疗保健，但原住民的肾移植率显著较低，这可能对他们接受肾脏替代治疗时的生存产生了不利影响。
