The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality

作者：Kraig Kinchen, John H. Sadler, Nancy E. Fink, Ronald S Brookmeyer, Michael J. Klag, Andrew S. Levey, Neil R. Powe · 发表于：Annals of Internal Medicine · 年份：2002 · DOI：10.7326/0003-4819-137-6-200209170-00007 · 被引用次数：465 · 研究领域：Dialysis and Renal Disease Management、Chronic Kidney Disease and Diabetes、Acute Kidney Injury Research

BACKGROUND: Care for chronic renal failure involves management of complications and preparation for possible dialysis. Patients often are not evaluated by nephrologists in a timely manner. OBJECTIVE: To identify factors associated with late evaluation by a nephrologist and to assess whether late evaluation is associated with worse survival once patients develop end-stage renal disease (ESRD). DESIGN: National prospective cohort study. SETTING: 81 dialysis facilities throughout the United States. PATIENTS: 828 patients with new-onset ESRD. MEASUREMENTS: Time from first evaluation by a nephrologist to initiation of dialysis, classified as late (<4 months), intermediate (4 to 12 months), or early (>12 months); rate of death, from initiation of dialysis to an average of 2.2 years of follow-up; and demographic, clinical, and laboratory characteristics. RESULTS: After adjustment for potential confounders, late evaluation was more common among black men than white men (44.8% vs. 24.5%; P < 0.05), uninsured patients than insured patients (56.7% vs. 29.0%; P < 0.05) and patients with severe comorbid disease than those with mild comorbid disease (35.0% vs. 23.0%; P < 0.05). Compared with patients who had early evaluation, the risk for death was greater among patients evaluated late and was graded (hazard ratio, 1.3 [95% CI, 0.87 to 2.06] for patients with intermediate evaluation and 1.8 [CI, 1.21 to 2.61] for those with late evaluation) after adjustment for dialysis method, demographic...