Garcia-Garcia Guillermo, Briseño-Rentería Gregorio, Luquín-Arellan Victor H, Gao Zhiwei, Gill John, Tonelli Marcello
Hospital Civil de Guadalajara, Hospital 278, 44280 Guadalajara, Jalisco, Mexico.
J Am Soc Nephrol. 2007 Jun;18(6):1922-7. doi: 10.1681/ASN.2006121388. Epub 2007 May 9.
ESRD is a serious public health problem in the state of Jalisco, Mexico. This study evaluated mortality in poor patients who initiated dialysis at the Jalisco Health Secretariat, compared with Hispanic patients without medical insurance who initiated dialysis in the United States. All patients who received a diagnosis with ESRD between February 1 and December 31, 2003, were studied prospectively at a single institution that provides care to the poor of Jalisco. Data from an American national dialysis registry and Cox proportional hazards models were used to compare the adjusted survival among Jalisco patients with that of a contemporaneous group of incident Hispanic patients who did not have Medicare or private insurance cover and who initiated peritoneal dialysis in the United States. Of 274 consecutive patients who presented with a clinical diagnosis of ESRD in Jalisco, mean estimated GFR at dialysis initiation was very low (3.9 +/- 2.4 ml/min per 1.73 m(2)), and <10% were previously known to a nephrologist. Of the 274 patients, 102 (37.2%) did not initiate dialysis therapy, 71 (69.6%) of whom died during follow-up. The majority (n = 49) of such deaths occurred in-hospital before dialysis initiation. Of 172 patients who initiated dialysis, 36 (20.9%) died within the first 90 d of renal replacement therapy. An additional 31 (18.0%) patients died during a median follow-up of 186 d. When all 274 Jalisco patients who presented with ESRD were considered, survival was 49.6% at the end of follow-up. Unadjusted mortality rates among those who survived at least 90 d after dialysis initiation were 19.2 (95% confidence interval [CI] 13.5 to 27.3) and 5.9 (95% CI 4.6 to 7.7) per 100 patient-years in Jalisco and American patients, respectively. After adjustment, the risk for death remained nearly three-fold higher in Jalisco patients (hazard ratio 2.7; 95% CI 1.5 to 4.7). Poor patients with kidney failure in Jalisco have very advanced disease at the time of first nephrologic contact and have exceedingly high rates of mortality after dialysis initiation. Our findings demonstrate a tremendous opportunity to reduce morbidity and mortality from kidney disease in Jalisco and perhaps other regions of Mexico.
终末期肾病（ESRD）是墨西哥哈利斯科州一个严重的公共卫生问题。本研究评估了在哈利斯科州卫生部开始透析的贫困患者的死亡率，并与在美国开始透析的无医疗保险的西班牙裔患者进行了比较。对2003年2月1日至12月31日期间被诊断为ESRD的所有患者，在一家为哈利斯科州贫困人口提供医疗服务的单一机构进行了前瞻性研究。使用来自美国国家透析登记处的数据和Cox比例风险模型，比较了哈利斯科州患者与同期一组在美国开始腹膜透析且没有医疗保险或私人保险覆盖的初发西班牙裔患者的校正后生存率。在哈利斯科州连续出现ESRD临床诊断的274例患者中，开始透析时的平均估计肾小球滤过率（GFR）非常低（3.9±2.4 ml/分钟/1.73 m²），并且不到10%的患者此前曾被肾病专家诊治过。在这274例患者中，102例（37.2%）未开始透析治疗，其中71例（69.6%）在随访期间死亡。此类死亡中的大多数（n = 49）发生在透析开始前的住院期间。在172例开始透析的患者中，36例（20.9%）在肾脏替代治疗的前90天内死亡。另外31例（18.0%）患者在中位随访期186天内死亡。当考虑所有274例出现ESRD的哈利斯科州患者时，随访结束时的生存率为49.6%。透析开始后至少存活90天的患者中，哈利斯科州患者和美国患者的未校正死亡率分别为每100患者年19.2（95%置信区间[CI] 13.5至27.3）和5.9（95% CI 4.6至7.7）。校正后，哈利斯科州患者的死亡风险仍然高出近三倍（风险比2.7；95% CI 1.5至4.7）。哈利斯科州患有肾衰竭的贫困患者在首次与肾病专家接触时疾病已非常严重，透析开始后的死亡率极高。我们的研究结果表明，在哈利斯科州以及墨西哥其他地区，有极大的机会降低肾病的发病率和死亡率。
