Schmidt R J, Domico J R, Sorkin M I, Hobbs G
West Virginia University School of Medicine, Department of Medicine, West Virginia University, Morgantown 26506-9165, USA.
Am J Kidney Dis. 1998 Aug;32(2):278-83. doi: 10.1053/ajkd.1998.v32.pm9708613.
Early referral (ER) to nephrologists of patients with chronic renal failure was assessed for its impact on the incidence of emergent first dialyses and choice of dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), and survival. We reviewed events preceding first dialyses of 238 patients with end-stage renal disease (ESRD) starting dialysis between January 1990 and April 1997, with follow-up extending through November 1997. Patients referred more than 1 month before needing dialysis (early referral [ER]) were compared with patients presenting within 30 days of needing dialysis (late referral [LR]). The need for emergent HD was significantly less among ER (29%) as compared with LR (90%) (P < 0.0001). Initial modality chosen was similar among ER patients (59% for HD v 41% for PD), a finding that contrasts with national percentages, which approximate 85% and 15%, respectively. Whereas most patients had not changed modality at 4 months, significantly more had changed from HD to PD (36 of 160 or 23%) than from PD to HD (7 of 78 or 9%) (P < 0.0001). Despite starting out on HD, ER and LR patients were amenable to ultimately changing to PD. ER and LR groups had similar numbers of Medicaid patients and patients living 1 hour or more distant to tertiary medical care. Furthermore, no difference was observed in the incidence of emergent HD when ER and LR living more than 1 hour away were compared. LR was not associated with lack of insurance or distance from referral site, although these patients more often required emergent HD, with its higher attendant medical care costs. Controlling for age and cause of ESRD, there was no statistically significant difference in long-term survival when ER patients were compared with LR patients or when patients who had received emergent HD were compared with those who had not. Despite the lack of difference in long-term survival, the financial costs of emergent HD alone merit greater promotion of ER and the psychosocial preparation and modality choice it allows.
对慢性肾衰竭患者早期转诊至肾病科医生的情况进行了评估，以了解其对首次紧急透析发生率、透析方式（血液透析[HD]或腹膜透析[PD]）选择及生存率的影响。我们回顾了1990年1月至1997年4月开始透析的238例终末期肾病（ESRD）患者首次透析前的相关事件，随访至1997年11月。将在需要透析前1个月以上转诊的患者（早期转诊[ER]）与在需要透析30天内就诊的患者（晚期转诊[LR]）进行比较。与LR组（90%）相比，ER组（29%）紧急HD的需求显著减少（P<0.0001）。ER组患者最初选择的透析方式相似（HD占59%，PD占41%），这一结果与全国比例（分别约为85%和15%）形成对比。虽然大多数患者在4个月时未改变透析方式，但从HD转为PD的患者（160例中的36例，即23%）显著多于从PD转为HD的患者（78例中的7例，即9%）（P<0.0001）。尽管开始时采用HD，但ER组和LR组患者最终都有可能转为PD。ER组和LR组中医疗补助患者以及居住在距三级医疗保健机构1小时或更远距离的患者数量相似。此外，比较居住在1小时路程以外的ER组和LR组患者时，紧急HD的发生率没有差异。LR与缺乏保险或距转诊地点的距离无关，尽管这些患者更常需要紧急HD，其伴随的医疗费用更高。在控制年龄和ESRD病因后，将ER组患者与LR组患者进行比较，或将接受紧急HD的患者与未接受紧急HD的患者进行比较，长期生存率在统计学上没有显著差异。尽管长期生存率没有差异，但仅紧急HD的财务成本就值得更大力推广ER及其所允许的心理社会准备和透析方式选择。
