O'Hare A M, Bertenthal D, Walter L C, Garg A X, Covinsky K, Kaufman J S, Rodriguez R A, Allon M
Department of Medicine, VA Medical Center and University of California, San Francisco, California 94121, USA. Ann.O'
Kidney Int. 2007 Mar;71(6):555-61. doi: 10.1038/sj.ki.5002078. Epub 2007 Jan 24.
To determine whether age should inform our approach toward permanent vascular access placement in patients with chronic kidney disease, we conducted a retrospective cohort study among 11 290 non-dialysis patients with an estimated glomerular filtration rate (eGFR) <25 ml/min/1.73 m(2) based on 2000-2001 outpatient creatinine measurements in the Department of Veterans Affairs. For each age group, we examined the percentage of patients that had and had not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis. We also modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines. The mean eGFR was 17.7 ml/min/1.73 m(2) at cohort entry. Twenty-five percent (n=2870) of patients initiated dialysis within a year of cohort entry. Among these, only 39% (n=1104) had undergone surgery to place a permanent access beforehand. As compared with younger patients, older patients were less likely to undergo permanent access surgery, but also less likely to start dialysis. In all theoretical scenarios examined, older patients would have been more likely than younger patients to receive unnecessary procedures. If all patients had been referred for permanent access surgery at cohort entry, the ratio of unnecessary to necessary procedures after 2 years of follow-up would have been 5:1 for patients aged 85-100 years but only 0.5:1 for those aged 18-44 years. Currently recommended approaches to permanent access placement based on a single threshold level of renal function for patients of all ages are not appropriate.
为了确定年龄是否应该影响我们对慢性肾病患者进行永久性血管通路置入的方法，我们在退伍军人事务部基于2000 - 2001年门诊肌酐测量结果的11290例估计肾小球滤过率（eGFR）<25 ml/min/1.73 m²的非透析患者中进行了一项回顾性队列研究。对于每个年龄组，我们检查了队列入组后1年内接受和未接受永久性血管通路的患者百分比，以及这些组中死亡、开始透析或未透析存活的患者百分比。我们还根据现有的血管通路指南，对理论场景中可能发生的不必要手术数量进行了建模。队列入组时的平均eGFR为17.7 ml/min/1.73 m²。25%（n = 2870）的患者在队列入组后1年内开始透析。在这些患者中，只有39%（n = 1104）预先接受了放置永久性血管通路的手术。与年轻患者相比，老年患者接受永久性血管通路手术的可能性较小，但开始透析的可能性也较小。在所有检查的理论场景中，老年患者比年轻患者更有可能接受不必要的手术。如果所有患者在队列入组时都被转诊进行永久性血管通路手术，那么在随访2年后，85 - 100岁患者的不必要手术与必要手术的比例将为5:1，而18 - 44岁患者的这一比例仅为0.5:1。目前基于单一肾功能阈值水平对所有年龄段患者进行永久性血管通路置入的推荐方法并不合适。
