Department of Nephrology, University Hospital, University Duisburg-Essen, Essen, Germany.
Int J Clin Pract. 2010 Dec;64(13):1784-92. doi: 10.1111/j.1742-1241.2010.02535.x.
To assess the impact of late referral (LR) for nephrological co-management compared with early referral (ER) on morbidity and mortality in chronic kidney disease (CKD) and to identify individual factors associated with higher mortality in LR, correcting for lead-time and immortal time bias.
Retrospective observational study comparing 46 LR patients with 103 ER patients. The quality of CKD management was assessed by measures to prevent CKD progression and to modify CKD complications and cardiovascular risk factors according to current guidelines. One-year mortality of LR and ER was compared and factors associated with mortality were identified. Analysis was performed with equivalent GFR (glomerular filtration rate) of ER and LR at baseline to correct for lead-time and immortal time bias.
Late referral was associated with inferior control of most risk factors for CKD progression, CKD complications and cardiovascular risk factors. In particular, glycaemic control, the use of angiotensin converting enzyme inhibitors and angiotensin-2-receptor blockers in diabetic nephropathy or proteinuria, the control of nutritional and volume status were inferior in LR. One-year mortality was significantly higher in LR (RR 5.9 (95% CI 1.5-19.6); p < 0.01). Inadequate control of blood pressure, anaemia, volume status, malnutrition and emergency initial dialysis, but not LR itself were independently associated with mortality.
Late referral was associated with a substantially lower survival after correction for lead-time and immortal time bias and with inferior control of most risk factors for CKD progression, complications and cardiovascular risk factors. CKD patients may particularly profit from adequate control of blood pressure, anaemia, nutritional and volume status, and avoidance of emergency initial dialysis as these factors may predominately contribute to survival.
评估肾脏内科共管的延迟转诊（LR）与早期转诊（ER）相比对慢性肾脏病（CKD）患者发病率和死亡率的影响，并确定与 LR 死亡率较高相关的个体因素，同时纠正领先时间和不朽时间偏倚。
回顾性观察性研究比较了 46 例 LR 患者和 103 例 ER 患者。根据现行指南，通过预防 CKD 进展和改善 CKD 并发症及心血管危险因素的措施来评估 CKD 管理质量。比较了 LR 和 ER 的 1 年死亡率，并确定了与死亡率相关的因素。分析时采用 ER 和 LR 基线等效肾小球滤过率（GFR），以纠正领先时间和不朽时间偏倚。
LR 与 CKD 进展、CKD 并发症和心血管危险因素的大多数控制不良相关。特别是，LR 患者的血糖控制、糖尿病肾病或蛋白尿患者的血管紧张素转换酶抑制剂和血管紧张素-2 受体阻滞剂的使用、营养和容量状态的控制均较差。LR 的 1 年死亡率显著更高（RR 5.9（95%CI 1.5-19.6）；p<0.01）。未控制的血压、贫血、容量状态、营养不良和急诊初始透析，但不是 LR 本身，与死亡率独立相关。
在纠正领先时间和不朽时间偏倚后，LR 与生存显著降低相关，并且与 CKD 进展、并发症和心血管危险因素的大多数控制不良相关。CKD 患者可能特别受益于适当控制血压、贫血、营养和容量状态，以及避免急诊初始透析，因为这些因素可能主要与生存相关。
