探討早期腎臟科轉介對血液透析病人在透析前照護、血管通路建立及死亡率的影響

Investigation Into Effects of Early Nephrology Referral on Pre-dialysis Care, Vascular Access Creation and Mortality in Hemodialysis Patients

背景：早期腎臟科轉介會降低血液透析病人的罹病率及死亡率。但在高末期腎臟病盛行率的南台灣卻鮮少探討。這個研究的目的主要是探討南台灣早期腎臟科轉介對血液透析病患生化數據、透析前照護、血管通路建立及死亡率的影響。方法：我們從1997年一月至2006年十二月收集了一間教學醫院集區域醫院的長期慢性血液透析病人，共267個病人。早期轉介定義為病人在首次血液透析前六個月以前曾因腎臟疾病看過腎臟科醫師門診（n＝153）；而延遲轉介則定義為病人在首次血液透析前六個月內才看過或從來沒看過腎臟科醫師門診（n＝123）。結果：與延遲轉介相比，早期轉介的病人在首次透析時較少有低白蛋白的情形、較長於腎臟科醫師看診、較多使用紅血球生成素及磷結合劑、且較少已做好永久性血管通路。經由多變相分析，早期轉介的病人與延遲轉介的病房相比有較多於透析前建立好血管通路（勝算比：3.080；p＜0.001）。另外，糖尿病則會增加血液透析病人的死亡率（危險比（HR）：2.697；p=0.005）。結論：我們的研究顯示出早期腎臟科轉介有較佳的生化數據、透析前照護及較多血管通路的建立，應加強極推廣對慢性腎臟病病患早期轉介的重要性。

Background. Early nephrology referral is associated with lower morbidity and mortality. Despite the high prevalence of end-stage renal disease (ESRD) in southern Taiwan there has been few related studies in this region. The aim of this study is to evaluate the benefits of early referral (ER) on the biochemical variables, pre-ESRD care, vascular access creation and mortality in hemodialysis patients in southern Taiwan. Methods. 276 patients were enrolled from January 1997 to December 2006 at one medical center and one regional hospital in southern Taiwan. ER and late referral (LR) were defined as referral to nephrologists greater or less than 6 months before the initiation of hemodialysis respectively. Results. When compared to LR patients, ER patients were less likely to have hypoalbuminemia at their first hemodialysis, more frequent nephrologists visits, were more likely to have received erythropoietin or phosphate binder therapy, and more likely to have a permanent vascular access for the first hemodialysis. Additionally, ER (odds ratio, 3.080; P ＜ 0.001) was significantly associated with predialysis vascular access placement. In multivariate analysis, diabetes mellitus (hazard ratio, 2.697; P = 0.005) was independently associated with increased mortality risk. Conclusions. Our findings show that ER results in better biochemical variables, better pre-ESRD care and more vascular access creation, reinforcing the importance of early nephrology referral in chronic kidney disease patients.