Wilson Barbara, Harwood Lori, Locking-Cusolito Heather, Chen Salina J, Heidenheim Paul, Craik Don, Clark William F
London Health Sciences Centre, London, Ontario, Canada.
Hemodial Int. 2007 Apr;11(2):263-9. doi: 10.1111/j.1542-4758.2007.00178.x.
Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.
尽管美国和加拿大都有关于开始透析时机的临床指南，但患者仍在预测肾小球滤过率（GFR）非常低的水平时开始透析。进行了一项横断面研究，以确定开始血液透析的患者的人口统计学和临床特征、他们的GFR水平以及透析开始后1年和2年的死亡率。收集了2001年3月至2005年2月在加拿大1个三级医疗中心开始慢性血液透析的所有符合条件患者的回顾性数据。仅纳入在透析开始前在慢性肾脏病诊所接受肾病专家随访的患者（n = 271）。17%的患者开始血液透析较晚（GFR<5 mL/min/1.73 m²）。与较早开始透析的患者组相比，晚开始组明显更年轻（p = 0.008），女性更多（p = 0.013），就业者更多（p = 0.051），心脏疾病（p<0.001）和外周血管疾病（p = 0.031）更少，并且正在服用抗高血压药物（p = 0.041）。晚开始组的血清白蛋白较低（p = 0.023）。在第1年，死亡率没有差异，而在第2年，透析越早，死亡率越高（p = 0.022）。在对人口统计学变量和合并症进行调整后，仅使用抗高血压药物与2年死亡率有独立但微弱的关联。对所有这些变量进行调整消除了早期与晚期透析开始时2年死亡率的显著关联。晚期与早期透析开始的生存获益似乎是多因素的，并且与晚期透析组中有利于延长生存的大量临床和人口统计学因素有关。我们的生存获益研究结果表明，病前健康状况是2年生存的比透析开始时机更重要的决定因素。
