Guidelines recommend that > or =50% of patients starting dialysis have a fistula. We reviewed our experience in consecutive incident patients over a 1-year period. Only 30 of the 93 patients starting hemodialysis had a fistula that was accessed. Late referral (nephrology contact <90 days) was a significant issue in 48% (30/63) of the patients without a fistula. Most (n=21) of the late referrals were acute disease; only 9 were late referrals of chronic disease. Nephrology follow-up exceeded 200 days in the remaining (33/63) without this access. In the cohort with sufficient nephrology referral, we explored variables associated with a fistula (n=30) compared with those without one (n=33). In multivariate logistic regression analysis, peripheral vascular disease (odds ratio [OR] 0.026, 95% confidence interval [CI] 0.002-0.286) and rapid loss of estimated glomerular filtration rate (eGFR) (OR 0.745 per mL/min/1.73 m(2)/year, 95% CI 0.625-0.888) in the year preceding dialysis were significant negative predictors for a fistula. Patients without access experienced faster declines in GFR in the year preceding dialysis (12.1+/-9.9 vs. 4.7+/-3.5 mL/min 1.73 m(2) with access, p<0.001). Glomerular filtration rate loss in the 2 years before starting dialysis was the same between the 2 groups (-0.54+/-10.4 vs. 1.42+/-3.9 mL/min 1.73 m(2)). Age, sex, diabetes, other comorbidity, length of nephrology follow-up, eGFR at dialysis start, hemoglobin, and albumin were not significant. At our center, rapid loss of renal function in otherwise stable chronic kidney disease (CKD) patients is more important than late referral of CKD for the lack of access. Improvements in rapid referral for access creation could help reduce this barrier.

译文

指南建议> 或> 50% 开始透析的患者有瘘管。我们回顾了我们在1年内连续事件患者中的经验。在开始进行血液透析的93例患者中,只有30例有瘘管。在48% (30/63) 无瘘管的患者中,晚期转诊 (肾脏病学接触 <90天) 是一个重要问题。大多数 (n = 21) 晚期转诊是急性病; 只有9例是慢性疾病的晚期转诊。在没有这种访问的情况下,肾脏病学随访超过200天 (33/63天)。在具有足够肾脏病转诊的队列中,我们探索了与瘘管相关的变量 (n = 30) 与没有瘘管的变量 (n = 33) 相比。在多变量logistic回归分析中,外周血管疾病 (优势比 [OR] 0.026,95% 置信区间 [CI] 0.002-0.286) 和估计肾小球滤过率 (eGFR) 的快速损失 (或0.745/mL/min/1.73 m(2)/年),透析前一年的95% CI 0.625-0.888) 是瘘管的显著阴性预测因子。没有通路的患者在透析前一年经历了更快的GFR下降 (12.1 +/-9.9 vs. 4.7 +/-3.5 mL/min 1.73 m(2),p<0.001)。开始透析前2年的肾小球滤过率损失在两组之间是相同的 (-0.54/-10.4对1.42/-3.9 mL/min 1.73 m(2))。年龄,性别,糖尿病,其他合并症,肾脏病随访时间,透析开始时的eGFR,血红蛋白和白蛋白均无显着性。在我们的中心,在其他稳定的慢性肾脏病 (CKD) 患者中,肾功能的快速丧失比由于缺乏进入而导致的CKD的晚期转诊更为重要。改善访问创建的快速转介可以帮助减少这一障碍。

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