Raffray Maxime, Urbanski Megan, Fallahzadeh Mohammad Kazem, Hu Chengcheng, Bayat-Makoei Sahar, Harding Jessica L
Division of Clinical Epidemiology, Karolinska Institutet, Solna, Sweden.
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Kidney Int Rep. 2025 Apr 1;10(6):1784-1794. doi: 10.1016/j.ekir.2025.03.043. eCollection 2025 Jun.
Individuals who initiate dialysis for kidney failure do so with different levels of preparedness. Whether this has downstream effects for access to kidney transplant is unknown.
We identified adults (aged ≥ 18 years) initiating dialysis between 2015 and 2019 from the United States Renal Data System and followed-up with them until waitlisting, death, or end of follow-up (December 31, 2021), whichever occurred first. We grouped dialysis initiation context as follows: group 1 initiated peritoneal dialysis (PD) or hemodialysis (HD) with mature arteriovenous access (AVA), group 2 initiated HD with a catheter and maturing AVA, group 3 initiated HD with a catheter and without a maturing AVA, and group 4 lacked predialysis nephrology care. Fine-Gray subdistribution hazard models were used to assess the association between dialysis initiation context and waitlisting, adjusted for clinical and nonclinical factors, and stratified by age, sex, race, and insurance status.
Among 541,861 adults initiating dialysis, 26.9%, 14.9%, 29.8%, and 28.4% were in groups 1, 2, 3, and 4, respectively. Compared with group 1, individuals in groups 2, 3, and 4 were 40% (adjusted hazard ratio [aHR]: 0.60; 95% confidence interval [CI]: 0.59-0.62), 45% (aHR: 0.55 [95% CI: 0.54-0.56]) and 58% (aHR: 0.42 [95% CI: 0.41-0.43]) less likely to be waitlisted. The relative impact of no predialysis nephrology care was most pronounced among older, Black, female, and Medicare insured patients.
A large proportion (∼60%) of adults in the US initiate dialysis with no AVA or predialysis nephrology care, with detrimental consequences for downstream transplant access.
因肾衰竭开始透析的个体其准备程度各不相同。这对肾移植的可及性是否有后续影响尚不清楚。
我们从美国肾脏数据系统中识别出2015年至2019年间开始透析的成年人（年龄≥18岁），并对他们进行随访，直至列入等待名单、死亡或随访结束（2021年12月31日），以先发生者为准。我们将开始透析的情况分为以下几组：第1组通过成熟的动静脉通路（AVA）开始腹膜透析（PD）或血液透析（HD），第2组通过导管和逐渐成熟的AVA开始HD，第3组通过导管且无逐渐成熟的AVA开始HD，第4组缺乏透析前肾病护理。使用精细灰色亚分布风险模型评估开始透析情况与列入等待名单之间的关联，并对临床和非临床因素进行调整，按年龄、性别、种族和保险状况进行分层。
在541,861名开始透析的成年人中，分别有26.9%、14.9%、29.8%和28.4%属于第1、2、3和4组。与第1组相比，第2、3和4组的个体列入等待名单的可能性分别降低了40%（调整后风险比[aHR]：0.60；95%置信区间[CI]：0.59 - 0.62）、45%（aHR：0.55[95%CI：0.54 - 0.56]）和58%（aHR：0.42[95%CI：0.41 - 0.43]）。透析前缺乏肾病护理的相对影响在年龄较大、黑人、女性和参加医疗保险的患者中最为明显。
美国很大一部分（约60%）成年人开始透析时没有AVA或透析前肾病护理，这对后续的移植可及性产生了不利影响。
