US Renal Data System的Chronic Disease Research Group提供部分資料協助。Slinin醫師指出，部分資金來自Minneapolis VA的年輕教職員臨床流行病學計畫。. Szczech醫師報告擔任Medicare和 Medicaid Services兩家保險中心的技術諮詢小組 ，從中接受報酬。
國家腎臟基金會(NKF) 2010春季臨床會議：壁報摘要236，發表於2010年4月14日。
Improper Dialysis Preparation Associated With Poor Survival Risk
By Deborah Brauser
Medscape Medical News
April 30, 2010 (Orlando, Florida) — Patients with end-stage kidney disease who meet the National Kidney Foundation's (NKF) 3 dialysis initiation guideline goals have a significantly better survival advantage than those who don't, according to the results of a retrospective evaluation of more than 190,000 patients, presented here at the NKF 2010 Spring Clinical Meetings.
More surprising was the finding that 59% of the patients didn't meet even 1 of the goals, reported Yelena Slinin, MD, assistant professor of medicine in the Division of Renal Diseases and Hypertension at the University of Minnesota in Minneapolis, and staff nephrologist at the Minneapolis VA Medical Center.
"Most of the research in the area of predialysis care has focused on getting patients to see kidney specialists early to allow for adequate time for dialysis preparation," said Dr. Slinin in a news release.
However, "according to our research, even patients who have been seen by kidney specialists for over a year come to dialysis poorly prepared," Dr. Slinin added during an interview with Medscape Nephrology.
The 3 predialysis goals from the NKF's Kidney Disease Outcomes Quality Initiative are that patients have a procedure done for effective and less infection-prone vascular access; have adequate levels of hemoglobin (to fight against anemia); and have adequate levels of blood albumin (to ensure good nutrition).
Arteriovenous fistulas are least likely to lead to infection and are longer lasting, and both fistulas and arteriovenous grafts produce better outcomes than tunneled dialysis catheters, reported Dr. Slinin. "Sadly, that is the most common vascular access at dialysis initiation."
Few Patients Meet Goals
Dr. Slinin and her team evaluated data from a cohort in the United States of 192,307 patients older than 20 years of age (mean age, 64.5 years) who started dialysis between June 2005 and May 2007. They sought to examine whether those who attained the 3 NKF goals had a first-year survival advantage.
The results showed that only 1% of the patients met all 3 goals, 9% met 2, 31% met just 1, and 59% met none of the goals.
The investigators also found that the more goals met, the more likely a patient was to survive their first year on dialysis. Compared with those who met none of the goals, those who met 1 goal had a 19% lower risk for death, those who met 2 goals had a 47% lower risk, and those meeting all 3 goals had a 66% lower risk (P?< .001 for all).
"Also, patients who had an arteriovenous graft or fistula in place had mortality reduced due to infection by 44%," reported Dr. Slinin. "Many of the early infectious deaths can potentially be prevented by having vascular access other than catheter at the start of dialysis."
In addition, the adjusted mortality hazard ratio for meeting hemoglobin at goal (>11?g/dL) was 0.94 (95% confidence interval [CI], 0.92?- 0.96) and for meeting albumin at goal was 0.67 (95% CI, 0.65?- 0.70).
"In other words, optimum albumin levels reduced mortality by 33% and adequate hemoglobin reduced it by 6%," said Dr. Slinin. "Our study emphasizes the benefit of predialysis care and the urgent need to define potential barriers to dialysis preparedness. We, as nephrologists, can do a better job; there is a lot of room for improvement."
She said that she would next like to study the reasons so few of these guideline goals are being met. "I think there are multiple, multiple factors that are playing into it, and what I want to do is tease those out so that we can intervene and improve things."
Drawing Attention
"I think this draws attention to one of the biggest concerns I have in translating benchmarks to quality improvement metrics," said incoming president of the NKF, Lynda Szczech, MD, associate professor of medicine at Duke University Medical Center in Durham, North Carolina.
"The fact that few of their patients met the goals aside, this study is interesting, it's valid, and it's something that we should look at," said Dr. Szczech, who was not involved with this analysis.
She noted that her biggest concern is that there is a lot about the goals that are not 100% within the control of the physician.
"Overall, I think one of the biggest things that we need to do in the renal community, and this [study] really draws attention to it, is to make third-party payers aware that the clinical performance benchmarks that we define for ourselves do not translate verbatim into good quality care on the payment side," concluded Dr. Szczech.
Some data assistance was provided by the Chronic Disease Research Group at the US Renal Data System. Dr. Slinin reports receiving some support from a clinical epidemiologic program for young faculty at the Minneapolis VA. Dr. Szczech reports serving on the technical advisory panel for the Centers for Medicare and Medicaid Services, from which she received an honorarium.
National Kidney Foundation (NKF) 2010 Spring Clinical Meetings: Abstract Poster?236. Presented April?14, 2010.
