UVSQ, INSERM, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Villejuif, France.
Service de Néphrologie, Dialyse, Transplantation Rénale et Aphérèse, CHU de Lille, Lille, France.
Nephrol Dial Transplant. 2021 Jul 23;36(8):1500-1510. doi: 10.1093/ndt/gfab170.
The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists.
The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that 'initiated imminently or <48 hours after presentation to correct life-threatening manifestations' according to the Kidney Disease: Improving Global Outcomes 2018 definition.
Over a 4-year (interquartile range 3.0-4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08-4.25] or with low health literacy [2.22 (95% CI 1.28-3.84)], heart failure [2.60 (95% CI 1.47-4.57)] or hyperpolypharmacy [taking >10 drugs; 2.14 (95% CI 1.17-3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19-1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70-0.94)] for each visit.
This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.
缺乏一项精心设计的前瞻性研究来确定紧急透析启动的决定因素，这促使我们调查了在接受肾病医生治疗的患者中，与个体和提供者相关的因素。
慢性肾脏病肾脏流行病学和信息网络（CKD-REIN）是一项前瞻性队列研究，纳入了 2013 年至 2016 年间来自 40 个具有全国代表性的肾病诊所的 3033 名慢性肾脏病患者[平均年龄 67 岁，65%为男性，平均估算肾小球滤过率（eGFR）为 32mL/min/1.73m2]，并在 2020 年之前每年进行随访。根据肾脏疾病：改善全球结果 2018 年的定义，紧急启动透析被定义为“立即开始或在就诊后 48 小时内开始，以纠正危及生命的表现”。
在 4 年（四分位间距 3.0-4.8）的中位随访期间，541 名患者开始透析，已知起始状态，其中 86 名（16%）被确定为紧急启动。5 年时紧急和非紧急透析启动、预先移植和死亡的竞争事件的风险分别为 4%、17%、3%和 15%。液体超负荷、电解质紊乱、急性肾损伤和手术后肾功能恶化是紧急启动透析的最常见原因。在独居患者（比值比 2.14 [95%置信区间 1.08-4.25]或低健康素养[2.22（95%置信区间 1.28-3.84]）、心力衰竭（比值比 2.60 [95%置信区间 1.47-4.57]）或高药物使用[服用>10 种药物；2.14（95%置信区间 1.17-3.90]）或高药物使用[服用>10 种药物；2.14（95%置信区间 1.17-3.90]）患者中，紧急启动的调整比值比显著更高，但与年龄或起始时的 eGFR 无关。在计划透析方式的患者中（比值比 0.46 [95%置信区间 0.19-1.10]）和在透析前 12 个月就诊次数更多的患者中（每次就诊比值比 0.81 [95%置信区间 0.70-0.94]），紧急启动的风险较低。
这项研究强调了一些与患者和提供者相关的重要因素，这些因素对于减少紧急启动透析的负担是需要解决的。
