Lai Mason, Gao Ying, Tavakol Mehdi, Freise Chris, Lee Brian K, Park Meyeon
School of Medicine, University of California San Francisco, San Francisco, California.
Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California.
Kidney360. 2022 Apr 18;3(6):1080-1088. doi: 10.34067/KID.0007652021. eCollection 2022 Jun 30.
The optimal timing of dialysis access placement in individuals with stage 5 CKD is challenging to estimate. Preemptive living donor kidney transplant (LDKT) is the gold-standard treatment for ESKD due to superior graft survival and mortality, but dialysis initiation is often required. Among LDKT recipients, we sought to determine which clinical characteristics were associated with preemptive transplant. Among non-preemptive LDKT recipients, we sought to determine what dialysis access was used, and their duration of use before receipt of living donor transplant.
We retrospectively extracted data on 569 LDKT recipients, >18 years old, who were transplanted between January 2014 and July 2019 at UCSF, including dialysis access type (arteriovenous fistula [AVF], arteriovenous graft [AVG], peritoneal dialysis catheter [PD], and venous catheter), duration of dialysis, and clinical characteristics.
Preemptive LDKT recipients constituted 30% of our cohort and were older, more likely to be White, more likely to have ESKD from polycystic kidney disease, and less likely to have ESKD from type 2 diabetes. Of the non-preemptive patients, 26% used AVF, 0.5% used AVG, 32% used peritoneal catheter, 11% used venous catheter, and 31% used more than one access type. Median (IQR) time on dialysis for AVF/AVG use was 1.86 (0.85-3.32) years; for PD catheters, 1.12 (0.55-1.92) years; for venous catheters, 0.66 (0.23-1.69) years; and for multimodal access, 2.15 (1.37-3.72) years.
We characterized the dialysis access landscape in LDKT recipients. Venous catheter and PD were the most popular modality in the first quartile of dialysis, and patients using these modalities had shorter times on dialysis compared with those with an AVF. Venous catheter or PD can be considered a viable bridge therapy in patients with living donor availability given their shorter waitlist times. Earlier referral of patients with living donor prospects might further minimize dialysis need.
估算5期慢性肾脏病（CKD）患者透析通路置入的最佳时机具有挑战性。由于移植物存活率更高且死亡率更低，择期活体供肾移植（LDKT）是终末期肾病（ESKD）的金标准治疗方法，但通常仍需要开始透析。在LDKT受者中，我们试图确定哪些临床特征与择期移植相关。在非择期LDKT受者中，我们试图确定使用了何种透析通路，以及在接受活体供肾移植前其使用时长。
我们回顾性提取了2014年1月至2019年7月期间在加州大学旧金山分校接受移植的569例年龄大于18岁的LDKT受者的数据，包括透析通路类型（动静脉内瘘[AVF]、动静脉移植物[AVG]、腹膜透析导管[PD]和静脉导管）、透析时长及临床特征。
择期LDKT受者占我们队列的30% , 年龄更大，更可能为白人，更可能因多囊肾病导致ESKD，而因2型糖尿病导致ESKD的可能性更小。在非择期患者中，26%使用AVF，0.5%使用AVG，32%使用腹膜导管，11%使用静脉导管，31%使用不止一种通路类型。使用AVF/AVG进行透析的中位（IQR）时间为1.86（0.85 - 3.32）年；使用PD导管为1.12（0.55 - 1.92）年；使用静脉导管为0.66（0.23 - 1.69）年；使用多模式通路为2.1（1.37 - 3.72）年。
我们描述了LDKT受者的透析通路情况。静脉导管和PD是透析前四分之一阶段最常用的方式，与使用AVF的患者相比，使用这些方式的患者透析时间更短。鉴于等待名单时间较短，静脉导管或PD可被视为有活体供肾的患者可行的过渡治疗。对于有活体供肾前景的患者更早转诊可能会进一步减少透析需求。
