Departments of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Taiwan.
Am J Med Sci. 2010 Feb;339(2):123-6. doi: 10.1097/MAJ.0b013e3181c0678a.
Early nephrology referral (ER) has been suggested to lower morbidity and mortality in dialysis patients, but the nature of the association has been criticized as possibly because of lead-time bias. This study aims to evaluate if ER is associated with improved survival of hemodialysis patients when the lead-time bias is excluded.
A total of 192 hemodialysis patients from a medical center and a regional hospital were enrolled in the period from January 1997 to December 2006. ER and late referral (LR) were defined as referral to nephrologists greater or less than 6 months, respectively, before the initiation of hemodialysis. Follow-up of clinical course in all patients was timed from the date at which estimate glomerular filtration rate was estimated to be 15 mL/min/1.73m. The relative overall survival was analyzed by Cox-regression adjusted for their demographic and comorbid conditions
Compared with LR patients, ER patients were less likely to have hypoalbuminemia in the beginning of hemodialysis, more likely to have received erythropoietin or phosphate binder therapy, more likely to have a vascular access created before the first hemodialysis, and had a slower rate of renal function decline before hemodialysis. In multivariate analysis, LR (hazard ratio: 2.827; P = 0.049) and diabetes mellitus were both independently associated with increased mortality risk. The survival benefits of ER seem to be originated from the period before initiation of renal replacement therapy.
Our findings show that ER is significantly associated with prolonged survival after exclusion of lead-time bias, which is consistent with ER being associated with better clinical outcomes in hemodialysis patients.
早期肾脏病学转诊（ER）被认为可以降低透析患者的发病率和死亡率，但这种关联的性质一直受到批评，因为可能存在领先时间偏倚。本研究旨在评估在排除领先时间偏倚后，ER 是否与血液透析患者的生存改善相关。
本研究共纳入了 192 名来自一家医学中心和一家地区医院的血液透析患者，入组时间为 1997 年 1 月至 2006 年 12 月。ER 和晚期转诊（LR）分别定义为在开始血液透析前的 6 个月内或 6 个月后转诊至肾脏病专家。所有患者的临床病程随访时间从估算肾小球滤过率估计为 15 mL/min/1.73m 时开始。通过 Cox 回归分析，调整患者的人口统计学和合并症状况，分析相对总体生存率。
与 LR 患者相比，ER 患者在开始血液透析时白蛋白水平较低的可能性较小，接受促红细胞生成素或磷酸盐结合剂治疗的可能性较大，在第一次血液透析前血管通路建立的可能性较大，肾功能下降的速度在血液透析前也较慢。多变量分析显示，LR（风险比：2.827；P = 0.049）和糖尿病均与死亡率增加独立相关。ER 的生存获益似乎源于开始肾脏替代治疗之前的时期。
我们的研究结果表明，在排除领先时间偏倚后，ER 与延长生存时间显著相关，这与 ER 与血液透析患者更好的临床结局相关的观点一致。
