Goel Narender, Kwon Caroline, Zachariah Teena P, Broker Michael, Folkert Vaughn W, Bauer Carolyn, Melamed Michal L
Division of Nephrology, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Avenue, Ullmann 615, Bronx, 10461, NY, USA.
Department of Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Avenue, Ullmann 615, Bronx, 10461, NY, USA.
BMC Nephrol. 2017 Jan 17;18(1):28. doi: 10.1186/s12882-016-0431-3.
The majority of incident hemodialysis (HD) patients initiate dialysis via catheters. We sought to identify factors associated with initiating hemodialysis with a functioning arterio-venous (AV) access.
We conducted a retrospective chart review of all adult patients, age >18 years seeing a nephrologist with a diagnosis of CKD stage 4 or 5 during the study period between 06/01/2011 and 08/31/2013 to evaluate the placement of an AV access, initiation of dialysis and we conducted a survey of providers about the process.
The 221 patients (56% female) in the study had median age of 66 years (interquartile range (IQR), 57-75) and were followed for a median of 1.26 years (IQR 0.6-1.68). At study entry, 81%had CKD stage 4 and 19% had CKD stage 5. By the end of study, 48 patients had initiated dialysis. Thirty-four of the patients started dialysis with a catheter (1 failed and 10 maturing AVFs), 9 with an AVF and 5 with an AVG. During the study period, 61 total AV accesses were placed (54 AVF and 7 AVG). A higher urinary protein/ creatinine ratio and a lower eGFR were associated with AV access placement and dialysis initiation. A greater number of nephrology visits were associated with AV access creation but not dialysis initiation. Hospitalizations and hospitalizations with an episode of acute kidney injury (AKI) were strongly associated with dialysis initiation (odds ratio (OR) 13.0 (95% confidence interval (CI) 2.3 to 73.3, p-value = 0.004) and OR 6.6 (95% CI 1.9 to 22.8, p-value = 0.003)).
More frequent nephrology clinic visits for patients with a recent hospitalization may improve rates of placement of an AV access. A hospitalization with AKI is strongly associated with the need for dialysis initiation. Nephrologists may not be referring the correct patients to get an AV access surgery.
大多数新开始血液透析（HD）的患者通过导管开始透析。我们试图确定与通过功能正常的动静脉（AV）通路开始血液透析相关的因素。
我们对2011年6月1日至2013年8月31日研究期间所有年龄大于18岁、因慢性肾脏病（CKD）4期或5期就诊于肾病科的成年患者进行了回顾性病历审查，以评估AV通路的建立、透析的开始情况，并对医疗服务提供者进行了关于该过程的调查。
研究中的221例患者（56%为女性）中位年龄为66岁（四分位间距（IQR），57 - 75岁），中位随访时间为1.26年（IQR 0.6 - 1.68）。研究开始时，81%患有CKD 4期，19%患有CKD 5期。到研究结束时，48例患者开始透析。其中34例患者通过导管开始透析（1例失败，10例自体动静脉内瘘（AVF）成熟），9例通过AVF开始透析，5例通过人工血管动静脉内瘘（AVG）开始透析。在研究期间，共建立了61条AV通路（54条AVF和7条AVG）。较高的尿蛋白/肌酐比值和较低的估算肾小球滤过率（eGFR）与AV通路建立及透析开始相关。更多的肾病科就诊次数与AV通路建立相关，但与透析开始无关。住院以及伴有急性肾损伤（AKI）发作的住院与透析开始密切相关（比值比（OR）13.0（95%置信区间（CI）2.3至73.3，p值 = 0.004）以及OR 6.6（95% CI 1.9至22.8，p值 = 0.003））。
近期住院患者更频繁地就诊于肾病科门诊可能会提高AV通路的建立率。伴有AKI的住院与开始透析的需求密切相关。肾病科医生可能没有将正确的患者转诊去进行AV通路手术。
