目的:终末期肾病自体动静脉(AV)通路创建后,大多数患者将继续接受血液透析(HD),少数人将接受肾脏移植的明确治疗,一部分患者将转换为腹膜透析(PD)。我们的目标是确定与从HD到肾移植或PD的早期过渡相关的患者因素。
方法:这是一项病例对照研究,对血管质量倡议(2011-2022)中首次建立房室通路的所有患者进行了长期随访。在AV通路创建后仍保持HD的患者为对照组,而接受早期肾脏移植或转换为PD的患者为两个病例组。人口统计学之间的关系,合并症,邻里社会劣势,评估了与肾脏替代治疗方式相关的功能状态。
结果:包括19,782例患者;平均年龄为62±15岁,男性占57%。在中位306(71-403)天的随访期间,1.3%接受了肾移植,2.3%接受了PD的转换。关于单变量分析,肾移植或转化为PD的比率因种族而异(P<.001),保险状况(P<.001),面积剥夺指数(ADI)五分之一(P<.001),和一些医疗合并症。在多变量分析中,行走受损,目前吸烟,医疗补助或医疗保险,黑人种族,心力衰竭,身体质量指数,年龄和年龄与移植率下降相关。转化为PD与ADIQ5、Q4和Q3相关。转化为PD的减少与步行障碍有关,西班牙裔种族,黑人种族,以前吸烟,药物控制的糖尿病,和老年。
结论:肾移植减少与黑人种族和非商业健康保险有关,但与ADI五分之一无关。表明在社区一级获得护理的机会之外存在差距。与HD和PD相比,早期肾脏移植带来了3年的生存益处。有相似的生存。需要进一步的工作来增加肾移植和PD的获得。
OBJECTIVE: After autogenous arteriovenous (AV) access creation for end-stage renal disease, a majority of patients will continue on hemodialysis (HD), a minority will receive definitive treatment with kidney transplantation, and a subset of patients will convert to peritoneal dialysis (PD). Our goal was to identify patient factors associated with early transition from HD to either kidney transplantation or PD.
METHODS: This is a case-control study of all patients with first-time AV access creation in the Vascular Quality Initiative (2011-2022) who had long-term follow-up. Patients who remained on HD after AV access creation were the control group while patients who received early kidney transplant or who converted to PD were the two case groups. Relationship among demographics, comorbidities, neighborhood social disadvantage, and functional status as they relate to renal replacement therapy modality was assessed.
RESULTS: There were 19,782 patients included; the average age was 62±15 years and 57% were male. During the follow-up period of a median 306 (71-403) days, 1.3% underwent a kidney transplantation and 2.3% underwent conversion to PD. On univariable analysis, rates of kidney transplantation or conversion to PD varied with race (P<.001), insurance status (P<.001), Area Deprivation Index (ADI) quintile (P<.001), and several medical comorbidities. On multivariable analysis, impaired ambulation, current smoking, Medicaid or Medicare insurance, Black race, heart failure, body mass index, and older age were associated with decreased transplantation rates. Conversion to PD was associated with ADI Q5, Q4, and Q3. Decreased conversion to PD was associated with impaired ambulation, Hispanic ethnicity, Black race, former smoking, medication-controlled diabetes, and older age.
CONCLUSIONS: Decreased kidney transplantation was associated with Black race and non-commercial health insurance but not ADI quintile, suggesting disparities exist beyond community-level access to care. Early kidney transplantation conveyed a 3-year survival benefit compared to HD and PD, which had similar survival. Further work is required to increase access to kidney transplantation and PD.