Dhanorkar Manoj, Prasad Narayan, Kushwaha Ravi, Behera Manas, Bhaduaria Dharmendra, Yaccha Monika, Patel Manas, Kaul Anupama
Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Int J Nephrol. 2022 Jun 1;2022:4768540. doi: 10.1155/2022/4768540. eCollection 2022.
CKD patients are often asymptomatic in the early stages and referred late to nephrologists. Late referred patients carry a poor prognosis. There is a lack of data on outcomes associated with referral patterns in CKD patients from northern India.
In this observational cohort study, all CKD patients who visited the nephrology OPD of the institute between Nov 1, 2018, and Dec 31, 2020, were classified as early referral (ER) if their first encounter with a nephrologist occurred more than one year before initiation of dialysis and education about dialysis (from a nurse or nephrologist). The remaining others were considered late referrals (LRs). The outcomes impact of early and late referrals was analyzed.
A total of 992 (male 656) CKD patients (ER, = 475 and LR, = 517) were enrolled. Patients referred early were older and diabetic and had higher BMI, better education, occupation, and socioeconomic status as compared to those referred late. The mean eGFR at first contact with the nephrologist was (25.4 ± 11.5 ml/min) in ER and 9.6 ± 5.7 ml/min in the LR group and had a higher comorbidity score. The CKD-MBD parameters, hemoglobin, and nutritional parameters were worse in LR. Only a few patients had AVF, and the majority required emergency dialysis in the LR group. A total of 91 (9.2%) patients died, 17 (1.7% ER and 74 (7.5%) patients in the LR group patients. There was significantly lower survival at 6 months (ER 97.1% vs. LR 89.7%), 12 months (ER 96.4% vs. LR 85.7%), 18 months (ER 96.4% vs. LR 85.7%), and 24 months (ER 96.4% vs. LR 85.7%) in late referral group as compared to early referral group (=0.005).
LR to nephrologists has the risk of the emergency start of dialysis with temporary vascular access and had a higher risk of mortality. The timely referral to the nephrologist in the predialysis stage is associated with better survival and reduced mortality.
慢性肾脏病（CKD）患者在疾病早期通常没有症状，往往在病情较晚时才转诊至肾病科医生处。转诊较晚的患者预后较差。在印度北部，缺乏关于CKD患者转诊模式相关结局的数据。
在这项观察性队列研究中，所有在2018年11月1日至2020年12月31日期间到该研究所肾病科门诊就诊的CKD患者，如果其首次与肾病科医生接触是在开始透析及接受透析教育（由护士或肾病科医生进行）前一年以上，则被分类为早期转诊（ER）。其余患者被视为晚期转诊（LR）。分析了早期和晚期转诊对结局的影响。
共纳入992例（男性656例）CKD患者（ER组475例，LR组517例）。与晚期转诊患者相比，早期转诊患者年龄更大、患有糖尿病，且体重指数更高、受教育程度更好、职业及社会经济地位更高。首次与肾病科医生接触时，ER组的平均估算肾小球滤过率（eGFR）为（25.4±11.5ml/min），LR组为9.6±5.7ml/min，且LR组合并症评分更高。LR组的CKD - MBD参数、血红蛋白及营养参数更差。只有少数患者有动静脉内瘘（AVF），LR组大多数患者需要紧急透析。共有91例（9.2%）患者死亡，其中ER组17例（1.7%），LR组74例（7.5%）。晚期转诊组在6个月（ER组97.1% vs. LR组89.7%）、12个月（ER组96.4% vs. LR组85.7%）、18个月（ER组96.4% vs. LR组85.7%）及24个月（ER组96.4% vs. LR组85.7%）时的生存率显著低于早期转诊组（P = 0.005）。
转诊至肾病科医生较晚的患者有通过临时血管通路紧急开始透析的风险，且死亡风险更高。在透析前阶段及时转诊至肾病科医生与更好的生存率及降低的死亡率相关。
