Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen East, 2100, Denmark.
BMC Nephrol. 2012 Sep 10;13:108. doi: 10.1186/1471-2369-13-108.
Many patients with advanced chronic kidney disease are referred late to renal units. This is associated with negative aspects. The purpose of the present study was to characterize late versus early referrals for renal replacement therapy including their renal disease, health care contacts and medical treatment before renal replacement therapy (RRT) and the consequences for RRT modality and mortality.
Nationwide cohort study including 4495 RRT patients identified in the Danish Nephrology Registry 1999-2006. The cohort was followed to end 2007 by linkage to other national registries. Late referral: follow-up ≤16 weeks in renal unit before RRT start. Cox proportional hazards models were used to estimate the relative risk of mortality or waiting list status within 365 days in late referrals versus early referrals.
A total of 1727 (38%) incident RRT patients were referred late. Among these, 72% were treated in non-nephrology hospital departments and 91% in general practice 2 years to 16 weeks before RRT start. Fewer late referrals received recommended pre-RRT treatment as judged by renin-angiotensin-system blockade: 32% versus 57% or the D-vitamin analogue alfacalcidol: 5% versus 30% (P < .001). Primary RRT modality was peritoneal dialysis: 18% in late versus 32% in early referrals (P < .001), 7% versus 30%, respectively, had an arteriovenous dialysis-fistula (P < .001) and 0.2% versus 6% were on the waiting-list for renal transplantation (P < .001) before RRT start. One-year-mortality was higher in late referrals: hazard ratio 1.55 (CI 95% 1.35-1.78). In a subgroup, 30% (CI 95% 25-35%) late and 9% (CI 95% 6-12%) early referrals had plasma creatinine ≤150% of upper reference limit within 1 to 2 years before RRT start (P < .001).
Late nephrology referrals were well-known to the healthcare system before referral for RRT start and more often had near normal plasma creatinine levels within 2 years before RRT start. They infrequently received available treatment or optimal first RRT modality. An increased effort to identify these patients in the healthcare system in time for proper pre-dialysis care including preparation for RRT is needed.
许多患有晚期慢性肾脏病的患者被延迟转诊至肾脏科。这与负面后果有关。本研究的目的是描述肾脏替代治疗（RRT）的晚期和早期转诊情况，包括其肾脏疾病、医疗保健接触情况和 RRT 前的医疗情况，以及对 RRT 方式和死亡率的影响。
本研究为一项全国性队列研究，纳入了丹麦肾脏病登记处 1999-2006 年期间确定的 4495 名 RRT 患者。通过与其他国家登记处的链接，对队列进行了 2007 年底的随访。晚期转诊：RRT 开始前，在肾脏科接受随访的时间≤16 周。使用 Cox 比例风险模型来估计晚期转诊与早期转诊相比，在 365 天内死亡或等待名单状态的相对风险。
共有 1727 名（38%）新确诊的 RRT 患者被延迟转诊。其中，72%在非肾病医院科室接受治疗，91%在普通科治疗，RRT 开始前 2 年至 16 周。接受评估的晚期转诊患者中，接受肾素-血管紧张素系统阻滞剂治疗的比例较低：32%比 57%；接受 D 维生素类似物阿法骨化醇治疗的比例较低：5%比 30%（P<.001）。主要的 RRT 方式是腹膜透析：晚期为 18%，早期为 32%（P<.001）；晚期分别有 7%和 30%有动静脉透析瘘（P<.001）；晚期分别有 0.2%和 6%在等待肾移植（P<.001）。晚期转诊患者的 1 年死亡率较高：风险比 1.55（95%CI 1.35-1.78）。在一个亚组中，30%（95%CI 25-35%）的晚期和 9%（95%CI 6-12%）的早期转诊患者在 RRT 开始前 1 至 2 年内，血浆肌酐水平≤参考上限的 150%（P<.001）。
晚期肾脏科转诊患者在开始 RRT 前已为医疗保健系统所熟知，且在 RRT 开始前 2 年内，他们的血浆肌酐水平更接近正常。他们很少接受可用的治疗或最佳的初始 RRT 方式。需要加大努力，及时在医疗保健系统中识别这些患者，以便进行适当的透析前护理，包括为 RRT 做准备。
