Division of Nephrology and Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; NSARF, National Taiwan University Hospital Study Group on Acute Renal Failure (NSARF), Taipei, Taiwan.
Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
Value Health. 2020 Sep;23(9):1225-1234. doi: 10.1016/j.jval.2020.01.024. Epub 2020 Aug 6.
Acute kidney injury (AKI) and acute kidney disease (AKD) are a continuum on a disease spectrum and frequently progress to chronic kidney disease. Benefits of nephrologist subspecialty care during the AKD period after AKI are uncertain.
Patients with AKI requiring dialysis who subsequently became dialysis independent and survived for at least 90 days, defined as the AKD period, were identified from the Taiwanese population's health insurance database. Cox proportional hazard models using death as the competing risk before and after propensity-score matching were applied to evaluate various endpoints.
Among a total of 20 260 patients with AKI requiring dialysis who became dialysis independent, only 7550 (37.3%) patients were followed up with by a nephrologist (F/U group) during the AKD period. During a mean 4.04 ± 3.56 years of follow-up, the patients in the F/U group were more often administered statin, antihypertensives, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), diuretics, antiplatelet agents, and antidiabetic agents. The patients in the F/U group had a lower mortality rate (hazard ratio [HR] = 0.87, P < .001) and were less likely to have major adverse cardiovascular events (MACE) (subdistribution HR [sHR] = 0.85, P < .001), congestive heart failure (CHF) (sHR = 0.81, P < .001), and severe sepsis (sHR = 0.88, P = .008) according to the Cox proportional model after adjusting for mortality as a competing risk. During the AKD period, an increase in the frequency of nephrology visits was associated with improved outcomes.
In this population-based cohort, even after weaning off acute dialysis, only a minority of patients visited a nephrologist during the AKD period. We showed that nephrology follow-up is associated with a decrease in MACE, CHF exacerbations, and sepsis, as well as lower mortality; thus it may improve outcomes in patients with AKD.
急性肾损伤（AKI）和急性肾疾病（AKD）是疾病谱上的连续体，常进展为慢性肾脏病。在 AKI 后 AKD 期间，肾脏病专家的专科护理的益处尚不确定。
从台湾全民健康保险数据库中确定了需要透析的 AKI 患者，这些患者随后实现了透析独立且至少存活了 90 天，定义为 AKD 期。使用 Cox 比例风险模型，将死亡作为倾向评分匹配前后的竞争风险，评估各种终点。
在总共 20260 名需要透析的 AKI 患者中，只有 7550 名（37.3%）患者在 AKD 期间接受了肾脏病专家的随访（随访组）。在平均 4.04±3.56 年的随访期间，随访组的患者更常接受他汀类药物、抗高血压药物、血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB）、利尿剂、抗血小板药物和抗糖尿病药物。随访组的死亡率较低（风险比 [HR] = 0.87，P <.001），且主要不良心血管事件（MACE）（亚分布 HR [sHR] = 0.85，P <.001）、充血性心力衰竭（CHF）（sHR = 0.81，P <.001）和严重败血症（sHR = 0.88，P =.008）的发生率较低，这是根据 Cox 比例模型调整死亡率作为竞争风险后得出的结果。在 AKD 期间，增加肾脏病就诊次数与改善结局相关。
在这项基于人群的队列研究中，即使在急性透析脱机后，只有少数患者在 AKD 期间就诊于肾脏病专家。我们发现，肾脏病随访与 MACE、CHF 恶化和败血症减少以及死亡率降低相关，因此可能改善 AKD 患者的结局。
