美国偏远和农村地区肾衰竭患者获得肾脏移植的情况。
Access to kidney transplantation among remote- and rural-dwelling patients with kidney failure in the United States.
作者信息
Tonelli Marcello, Klarenbach Scott, Rose Caren, Wiebe Natasha, Gill John
机构信息
Department of Medicine, University of Alberta, Edmonton, AB T6B 2B7, Canada.
出版信息
JAMA. 2009 Apr 22;301(16):1681-90. doi: 10.1001/jama.2009.545.
CONTEXT
US residents with end-stage renal disease (ESRD) may live far away from the closest transplant center, which could compromise their access to kidney transplantation.
OBJECTIVE
To assess access to kidney transplantation as a function of distance from the closest transplant center or as a function of rural rather than urban residence.
DESIGN, SETTING, AND PARTICIPANTS: Observational study of 699,751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were thus placed on a prospective mandatory registry list.
MAIN OUTCOME MEASURES
Time to placement on the kidney transplant waiting list and time to kidney transplantation, both measured at the start of renal replacement.
RESULTS
During a median follow-up of 2.0 years (range, 0.0-12.5 years), 122,785 (17.5%) patients received a kidney transplant. Median distance to the closest transplant center was 15 miles. Participants were classified into distance categories by miles from a transplant center with 0 to 15 miles serving as the referent category. Compared with the referent category, the adjusted hazard ratios of deceased or living donor transplantation within each category follows: 16 to 50 miles, 1.03 (95% CI, 1.02-1.05); 51 to 100 miles, 1.11 (95% CI, 1.09-1.12); 101 to 136 miles, 1.14 (95% CI, 1.11-1.17); 137 to 231 miles, 1.16 (95% CI, 1.13-1.20); 232 to 310 miles, 1.20 (95% CI, 1.12-1.28); and more than 310 miles, 1.16 (95% CI, 1.09-1.23). When residence location was classified using rural-urban commuter areas, 79.6% of patients lived in urban; 10.3%, micropolitan; and 10.0%, rural areas. Compared with those living in metropolitan areas, the adjusted hazard ratios of deceased or living donor transplantation among patients residing in micropolitan communities was 1.13 (95% CI, 1.11-1.15) and 1.15 (95% CI, 1.13-1.18) for rural areas. Results were similar for both deceased donor and living donor transplantation and were consistent in multiple sensitivity analyses.
CONCLUSION
Remote or rural residence was not associated with increased time to kidney transplantation among people treated for ESRD in the United States.
背景
美国终末期肾病（ESRD）患者可能居住在距离最近的移植中心很远的地方，这可能会影响他们接受肾脏移植的机会。
目的
评估距离最近的移植中心的远近或居住在农村而非城市地区对接受肾脏移植机会的影响。
设计、地点和参与者：对1995年至2007年间在美国开始进行肾脏替代治疗并因此被列入前瞻性强制登记名单的699751例成年肾衰竭患者进行观察性研究。
主要观察指标
在开始肾脏替代治疗时测量的进入肾脏移植等待名单的时间和接受肾脏移植的时间。
结果
在中位随访2.0年（范围0.0 - 12.5年）期间，122785例（17.5%）患者接受了肾脏移植。到最近移植中心的中位距离为15英里。参与者根据与移植中心的距离分为不同类别，以0至15英里为参照类别。与参照类别相比，各距离类别内死者或活体供体移植的调整后风险比分别为：16至50英里，1.03（95%置信区间，1.02 - 1.05）；51至100英里，1.11（95%置信区间，1.09 - 1.12）；101至136英里区域，1.14（95%置信区间，1.11 - 1.17）；137至231英里区域，1.16（95%置信区间，1.13 - 1.20）；232至310英里区域，1.20（95%置信区间，1.12 - 1.28）；超过310英里区域，1.16（95%置信区间，1.09 - 1.23）。当根据城乡通勤区域对居住地点进行分类时，79.6%的患者居住在城市；10.3%居住在微型都市；10.0%居住在农村地区。与居住在大都市地区的患者相比，居住在微型都市社区患者的死者或活体供体移植调整后风险比为1.13（95%置信区间，1.11 - 1.15），农村地区患者为1.15（95%置信区间，1.13 - 1.18）。死者供体移植和活体供体移植的结果相似，并且在多项敏感性分析中保持一致。
结论
在美国，接受ESRD治疗的患者中，居住在偏远或农村地区与接受肾脏移植的时间延长无关。
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