花房規男, 阿部雅紀, 常喜信彦ほか：わが国の慢性透析療法の現況（2022年12月31日現在）. 日本透析医学会雑誌 2023；56（12）：473～536.
United States Renal Data System. 2020 USRDS Annual Data Report：Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
Collins AJ, Foley RN, Herzog C, Chavers B, Gilbertson D, Herzog C, Ishani A, Johansen K, Kasiske B, Kutner N, Liu J, St Peter W, Ding S, Guo H, Kats A, Lamb K, Li S, Li S, Roberts T, Skeans M, Snyder J, Solid C, Thompson B, Weinhandl E, Xiong H, Yusuf A, Zaun D, Arko C, Chen SC, Daniels F, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L.
US Renal Data System 2012 Annual Data Report.
Am J Kidney Dis. 2013 Jan;61(1 Suppl 1):A7, e1-476. doi: 10.1053/j.ajkd.2012.11.031.
Abstract/Text
Abe M, Shiga H, Tatsumi H, Endo Y, Kikuchi Y, Suzuki Y, Doi K, Nakada TA, Nagafuchi H, Hattori N, Hirohashi N, Moriguchi T, Yamaga O, Nishida O.
Results of the 2018 Japan Society for Blood Purification in Critical Care survey: current status and outcomes.
Ren Replace Ther. 2022;8(1):58. doi: 10.1186/s41100-022-00445-0. Epub 2022 Nov 12.
Abstract/Text
BACKGROUND: The Japan Society for Blood Purification in Critical Care (JSBPCC) has reported survey results on blood purification therapy (BPT) for critically ill patients in 2005, 2009, and 2013. To clarify the current clinical status, including details of the modes used, treated diseases, and survival rate, we conducted this cohort study using data from the nationwide JSBPCC registry in 2018.
METHODS: We analyzed data of 2371 patients who underwent BPT in the intensive care units of 43 facilities to investigate patient characteristics, disease severity, modes of BPTs, including the dose of continuous renal replacement therapy (CRRT) and hemofilters, treated diseases, and the survival rate for each disease. Disease severity was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores.
RESULTS: BPT was performed 2867 times in the 2371 patients. Mean APACHE II and SOFA scores were 23.5 ± 9.4 and 10.0 ± 4.4, respectively. The most frequently used mode of BPT was CRRT (67.4%), followed by intermittent renal replacement therapy (19.1%) and direct hemoperfusion with the polymyxin B-immobilized fiber column (7.3%). The most commonly used anticoagulant was nafamostat mesilate (78.6%). Among all patients, the 28-day survival rate was 61.7%. CRRT was the most commonly used mode for many diseases, including acute kidney injury (AKI), multiple organ failure (MOF), and sepsis. The survival rate decreased according to the severity of AKI (P = 0.001). The survival rate was significantly lower in patients with multiple organ failure (MOF) (34.6%) compared with acute lung injury (ALI) (48.0%) and sepsis (58.0%). Multivariate logistic regression analysis revealed that sepsis, ALI, acute liver failure, cardiovascular hypotension, central nervous system disorders, and higher APACHE II scores were significant predictors of higher 28-day mortality.
CONCLUSION: This large-scale cohort study revealed the current status of BPT in Japan. It was found that CRRT was the most frequently used mode for critically ill patients in Japan and that 28-day survival was lower in those with MOF or sepsis. Further investigations are required to clarify the efficacy of BPT for critically ill patients.Trial Registration: UMIN000027678.
SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41100-022-00445-0.
© The Author(s) 2022.
川口良人, 二瓶宏, 平沢由平ほか, 透析導入ガイドラインの作成に関する研究,平成3年度厚生科学研究：腎不全医療研究事業報告書（班長：三村信英）. 1992, 国立佐倉病院: 佐倉. p. 125-132.
秋澤忠男, 水口潤, 友雅司ほか：維持血液透析ガイドライン 血液透析導入．日本透析医学会雑誌46:1107-1155,2013.
AKI（急性腎障害）診療ガイドライン作成委員会編：AKI（急性腎障害）診療ガイドライン 2016年版, 東京医学社，2016.
Kidney Disease: Improving Global Outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012; 2: 1-138.
腎不全 治療選択とその実際. 日本腎臓学会，日本透析医学会，日本移植学会，日本臨床腎移植学会編. 大阪, 2012.
Hemodialysis Adequacy 2006 Work Group.
Clinical practice guidelines for hemodialysis adequacy, update 2006.
Am J Kidney Dis. 2006 Jul;48 Suppl 1:S2-90. doi: 10.1053/j.ajkd.2006.03.051.
Abstract/Text
European Best Practice Guidelines Expert Group on Hemodialysis, European Renal Association.
Section I. Measurement of renal function, when to refer and when to start dialysis.
Nephrol Dial Transplant. 2002;17 Suppl 7:7-15. doi: 10.1093/ndt/17.suppl_7.7.
Abstract/Text
Bonomini V, Feletti C, Scolari MP, Stefoni S.
Benefits of early initiation of dialysis.
Kidney Int Suppl. 1985 Dec;17:S57-9.
Abstract/Text
Susantitaphong P, Altamimi S, Ashkar M, Balk EM, Stel VS, Wright S, Jaber BL.
GFR at initiation of dialysis and mortality in CKD: a meta-analysis.
Am J Kidney Dis. 2012 Jun;59(6):829-40. doi: 10.1053/j.ajkd.2012.01.015. Epub 2012 Apr 1.
Abstract/Text
BACKGROUND: The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis therapy at a higher glomerular filtration rate (GFR) has increased during the past decade. Recent data suggest that higher GFR may be associated with increased mortality.
STUDY DESIGN: A meta-analysis of cohort studies and trials.
SETTING & POPULATION: Patients with advanced CKD.
SELECTION CRITERIA FOR STUDIES: We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis therapy initiation and mortality.
PREDICTOR: Estimated or calculated GFR at dialysis therapy initiation.
OUTCOME: Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality.
RESULTS: 16 cohort studies and 1 randomized controlled trial were identified (n = 1,081,116). By meta-analysis restricted to 15 cohorts (n = 1,079,917), higher GFR at dialysis therapy initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03-1.05; P < 0.001). However, there was significant heterogeneity (I(2) = 97%; P < 0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001; residual I(2) = 97%). The highest mortality risk was observed in hemodialysis cohorts (HR, 1.05; 95% CI, 1.02-1.08; P < 0.001), whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR, 1.04; 95% CI, 0.99-1.08, P = 0.1; residual I(2) = 98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR, 0.80; 95% CI, 0.71-0.91; P = 0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR, 1.04; 95% CI, 1.03-1.05; P < 0.001; residual I(2) = 97%).
LIMITATIONS: Paucity of randomized controlled trials, different methods for determining GFR, and substantial heterogeneity.
CONCLUSIONS: Higher estimated rather than calculated GFR at dialysis therapy initiation is associated with a higher mortality risk in patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study.
Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA; IDEAL Study.
A randomized, controlled trial of early versus late initiation of dialysis.
N Engl J Med. 2010 Aug 12;363(7):609-19. doi: 10.1056/NEJMoa1000552. Epub 2010 Jun 27.
Abstract/Text
BACKGROUND: In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease.
METHODS: We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause.
RESULTS: Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis).
CONCLUSIONS: In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)
Harris A, Cooper BA, Li JJ, Bulfone L, Branley P, Collins JF, Craig JC, Fraenkel MB, Johnson DW, Kesselhut J, Luxton G, Pilmore A, Rosevear M, Tiller DJ, Pollock CA, Harris DC.
Cost-effectiveness of initiating dialysis early: a randomized controlled trial.
Am J Kidney Dis. 2011 May;57(5):707-15. doi: 10.1053/j.ajkd.2010.12.018. Epub 2011 Feb 23.
Abstract/Text
BACKGROUND: Planned early initiation of dialysis therapy based on estimated kidney function does not influence mortality and major comorbid conditions, but amelioration of symptoms may improve quality of life and decrease costs.
STUDY DESIGN: Patients with progressive chronic kidney disease and a Cockcroft-Gault estimated glomerular filtration rate of 10-15 mL/min/1.73 m(2) were randomly assigned to start dialysis therapy at a glomerular filtration rate of either 10-14 (early start) or 5-7 mL/min/1.73 m(2) (late start).
SETTING & POPULATION: Of the original 828 patients in the IDEAL (Initiation of Dialysis Early or Late) Trial in renal units in Australia and New Zealand, 642 agreed to participate in this cost-effectiveness study. STUDY PERSPECTIVE & TIMEFRAME: A societal perspective was taken for costs. Patients were enrolled between July 1, 2000, and November 14, 2008, and followed up until November 14, 2009.
INTERVENTION: Planned earlier start of maintenance dialysis therapy.
OUTCOMES: Difference in quality of life and costs.
RESULTS: Median follow-up of patients (307 early start, 335 late start) was 4.15 years, with a 6-month difference in median duration of dialysis therapy. Mean direct dialysis costs were significantly higher in the early-start group ($10,777; 95% CI, $313 to $22,801). Total costs, including costs for resources used to manage adverse events, were higher in the early-start group ($18,715; 95% CI, -$3,162 to $43,021), although not statistically different. Adjusted for differences in baseline quality of life, the difference in quality-adjusted survival between groups over the time horizon of the trial was not statistically different (0.02 full health equivalent years; 95% CI, -0.09 to 0.14).
LIMITATIONS: Missing quality-of-life questionnaires and skewed cost data, although similar in each group, decrease the precision of results.
CONCLUSION: Planned early initiation of dialysis therapy in patients with progressive chronic kidney disease has higher dialysis costs and is not associated with improved quality of life.
Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Charlson ME, Pompei P, Ales KL, MacKenzie CR.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
J Chronic Dis. 1987;40(5):373-83. doi: 10.1016/0021-9681(87)90171-8.
Abstract/Text
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Yamagata K, Nakai S, Masakane I, Hanafusa N, Iseki K, Tsubakihara Y; Committee of Renal Data Registry of the Japanese Society for Dialysis Therapy.
Ideal timing and predialysis nephrology care duration for dialysis initiation: from analysis of Japanese dialysis initiation survey.
Ther Apher Dial. 2012 Feb;16(1):54-62. doi: 10.1111/j.1744-9987.2011.01005.x. Epub 2011 Nov 3.
Abstract/Text
Previous studies have suggested that early initiation of dialysis therapy was not superior in terms of patient survival. In this study, we analyzed the effects of renal function at the start of renal replacement therapy (RRT), duration of nephrology care, and comorbidity on 12-month survival of end-stage renal disease (ESRD) patients. The subjects in this study were 9695 new ESRD patients who started RRT in 2007. The average age of the subjects was 67.5 years, 64.1% of the subjects were male, and 42.9% had diabetes. During the 12-month period after the start of RRT, 1546 patients died, and 35 patients received renal transplantation. Average estimated glomerular filtration rate (eGFR) at the initiation of dialysis was 6.52 ± 4.20 mL/min/1.73 m(2) . By unadjusted logistic analysis, one-year Odds Ratio (OR) of mortality in patients with eGFR more than 4-6 mL/min/1.73 m(2) was increased with increased eGFR at dialysis initiation, but the OR was identical among the groups with eGFR less than 4 mL/min/1.73 m(2) . After adjustment for age, gender, underlying renal diseases, and other clinical characteristics at dialysis initiation, OR was identical among the groups with eGFR less than 8 mL/min/1.73 m(2) . Furthermore, an OR increment was observed in eGFR less than 4 mL/min/1.73 m(2) group. In terms of the duration of nephrology care before dialysis initiation, 6 months or longer of nephrology care significantly decreased the OR of mortality after adjustment of covariance. Not only patients with sufficient residual renal function at the initiation of dialysis, but also patients with very low eGFR at the initiation of dialysis showed poor survival.
© 2011 The Authors. Therapeutic Apheresis and Dialysis © 2011 International Society for Apheresis.
社団法人 日本透析医学会編 慢性血液透析用バスキュラーアクセスの作製および修復に関するガイドライン 透析会誌 2011年版, 44(9), 855-937, 2011.
Vascular Access Work Group.
Clinical practice guidelines for vascular access.
Am J Kidney Dis. 2006 Jul;48 Suppl 1:S248-73. doi: 10.1053/j.ajkd.2006.04.040.
Abstract/Text
Chesser AM, Baker LR.
Temporary vascular access for first dialysis is common, undesirable and usually avoidable.
Clin Nephrol. 1999 Apr;51(4):228-32.
Abstract/Text
BACKGROUND: When technically feasible, patients with end-stage renal failure should commence regular dialysis treatment with permanent access to the circulation (by arteriovenous fistula) or peritoneum (by soft peritoneal catheter) in situ, thus avoiding the need for initial hemodialysis employing temporary vascular access. We have examined the frequency, consequences and avoidability of temporary access in such patients.
METHODS: 178 patients commencing regular dialysis between August 1993 and April 1995 were analysed retrospectively using case notes. Patients were divided into those who had permanent dialysis access in situ when they commenced dialysis and those who required temporary access. If temporary access was required, the patients were further analysed into those who had been first seen by a nephrologist at least 12 weeks before the first dialysis, and those who had been referred "late". It was assumed that 12 weeks was sufficient time for permanent access to be instituted. Mortality within the first 90 days of commencing dialysis was recorded.
RESULTS: Seventy-four of 82 patients opting for regular hemodialysis and 53 of 96 opting for peritoneal dialysis required temporary vascular access. Late referral accounted for 47 and delays within the renal service for 35 of such patients. Late presentation to the medical profession or indecisiveness on the part of the patient accounted for the remainder. Twenty-five of 127 patients requiring temporary access but only one or 51 patients not requiring it died within 90 days of commencement of treatment.
CONCLUSION: Late presentation to a renal unit prior to first dialysis is associated with increased mortality. Late referral or late presentation are associated with an increased need for temporary vascular access for first dialysis. Many patients who require temporary access for first dialysis could have been better managed.
Lorenzo V, Martn M, Rufino M, Hernández D, Torres A, Ayus JC.
Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study.
Am J Kidney Dis. 2004 Jun;43(6):999-1007. doi: 10.1053/j.ajkd.2004.02.012.
Abstract/Text
BACKGROUND: Late nephrologist referral may adversely affect outcome in patients initiating maintenance hemodialysis therapy, mostly with temporary catheters that may further increase morbidity and mortality. Our aim was to evaluate the influence of 2 variables on mortality: presentation mode (planned versus unplanned) and type of access (arteriovenous fistula [AVF] versus temporary catheter) at entry.
METHODS: This was a 3-center, 5-year, prospective, observational, cohort study of 538 incident patients. Measurements included presentation mode, type of access, renal function and biochemical test results at entry, and stratification of risk groups. Main outcome measures were mortality and hospitalization.
RESULTS: Of 281 planned patients (52%), 73% initiated therapy with an AVF. Of 257 unplanned patients (48%), 70% initiated therapy with a catheter (P < 0.001). Multivariate Cox analysis showed that unplanned presentation (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.23 to 2.44) and initiation of therapy with catheter (HR, 1.75; 95% CI, 1.25 to 2.46) were independently associated with greater mortality and similar HRs after adjusting for confounders. At 12 months, the number of deaths was 3 times higher in both the unplanned versus planned groups and catheter versus AVF groups. The joint effect of unplanned dialysis initiation and catheter use had an additive impact on mortality (HR, 2.89; 95% CI, 1.97 to 4.22). Greater hematocrit (HR, 1.04; 95% CI, 1.01 to 1.09) and albumin level (HR, 1.79; 95% CI, 1.37 to 2.33) showed an independent association with survival, underscoring the benefits of predialysis care. Using Poisson regression, all-cause hospitalization (incidence rate ratio, 1.56; 95% CI, 1.36 to 1.79; P < 0.001) and infection-related (incidence rate ratio, 2.62; 95% CI, 1.91 to 3.59; P < 0.001) and vascular access-related (incidence rate ratio, 1.49; 95% CI, 1.15 to 1.94; P < 0.003) admissions were higher in unplanned patients initiating therapy with a catheter than in planned patients initiating therapy with an AVF, after adjusting for confounders.
CONCLUSION: Unplanned dialysis initiation and temporary catheter were independently associated with greater mortality rates in incident patients. The combined influence of both variables was associated with greater morbidity and mortality than either variable alone.
Wu LC, Lin MY, Hsieh CC, Chiu HC, Mau LW, Chiu YW, Chen HC, Hwang SJ.
Planned creation of vascular access saves medical expenses for incident dialysis patients.
Kaohsiung J Med Sci. 2009 Oct;25(10):521-9. doi: 10.1016/S1607-551X(09)70544-3.
Abstract/Text
Hospitalization to initiate hemodialysis (HD) through temporary catheterization and subsequent creation of permanent vascular access (VA) is costly. Therefore, we studied the influence of the timing of VA creation on medical expenses, length of stay (LOS) and 1-year primary patency rate in incident HD patients. We analyzed the medical expenses associated with hospitalization and LOS at VA creation in 486 incident HD patients at two hospitals in southern Taiwan. Patients with early VA creation, more than 1 month before HD initiation, were defined as the Planned group (n = 70); less than 1 month as the Delayed group (n = 48); and those with VA creation after the initiation of HD as the Urgent group (n = 368). The Urgent group had the highest inpatient medical expenses and LOS compared with the other two groups. Multiple regression analyses of inpatient medical expenses and LOS showed that the timing of VA creation, the type of VA, marital and employment status and the number of comorbidities were significant factors responsible for the differences between groups. Furthermore, higher inpatient medical expenses and longer LOS in the Urgent group were noted in the arteriovenous fistula and arteriovenous graft subgroups. Kaplan-Meier Survival analysis showed that the 1-year primary patency rate was highest in the Delayed group and lowest in the Planned group, while Cox regression analysis demonstrated that the type of VA, but not the timing of VA creation, was a significant risk factor for VA patency. Arteriovenous graft had a higher risk for occlusion than arteriovenous fistula. In conclusion, planned VA creation before the initiation of HD is associated with lower inpatient medical expenses and shorter LOS, which should be promoted for pre-end-stage renal disease care, but the care for VA should be further emphasized before the progression to end-stage renal disease, and the patency of the VA should be cautiously monitored.
日本透析医学会：わが国の慢性透析療法の現況 2008年12月31日現在. 2009.
腹膜透析ガイドライン改訂グループ編：腹膜透析ガイドライン2019, 医学図書出版, 東京, 2019.
中山昌明，川西秀樹，友雅司，他：2009年版 日本透析医学会「腹膜透析ガイドライン」透析会誌2009；42：285-315.
Tang SC, Ho YW, Tang AW, Cheng YY, Chiu FH, Lo WK, Lai KN; Hong Kong Peritoneal Dialysis Study Group.
Delaying initiation of dialysis till symptomatic uraemia--is it too late?
Nephrol Dial Transplant. 2007 Jul;22(7):1926-32. doi: 10.1093/ndt/gfm109. Epub 2007 Mar 30.
Abstract/Text
BACKGROUND: The optimal timing of initiating renal replacement therapy in patients with chronic renal failure remains uncertain. The primary objective of our study is to determine whether delaying dialysis initiation as a result of patients' choice may have any impact on survival in subjects with end-stage renal disease.
METHODS: We prospectively studied the clinical outcome during the first year of all consecutive patients (n=233) deemed suitable for peritoneal dialysis (PD) after pre-dialysis counselling over a 2-year period from 2002 to 2004. All patients who were offered dialysis were included in the analysis from the day of initial counselling regardless of whether or not they were eventually established on PD.
RESULTS: There were 151 'elective starters' (50.3% male, mean+/-SD age=57.7+/-13.9 years, 39.7% diabetic) who were electively initiated on dialysis when glomerular filtration rate reached 10 ml/min/1.73 m2 or below. The remaining 82 subjects (53.7% male, mean+/-SD age=58.4+/-11.3 years, 46.3% diabetic, P=0.33 vs elective starters) declined dialysis initially (initial refusers). On follow-up, 45 (55%) initial refusers developed a uraemic emergency and agreed to undergo dialysis, and 39 (48%) were eventually established on maintenance PD (late starters). Kaplan-Meier analysis of 1-year survival showed a significantly higher rate of all-cause (18.3% vs 6.6%, P=0.004, log-rank test) and cardiovascular (9.8% vs 2.6%, P=0.014) mortality among the initial refusers.
CONCLUSION: Patients who refuse timely start of dialysis have worse overall outcome at one year after the offer of dialysis, compared with elective starters.
Mehrotra R, Nolph KD.
Treatment of advanced renal failure: low-protein diets or timely initiation of dialysis?
Kidney Int. 2000 Oct;58(4):1381-8. doi: 10.1046/j.1523-1755.2000.00300.x.
Abstract/Text
Until 1996, no guidelines existed for the initiation of dialysis in patients with progressive renal failure. The publication of the National Kidney Foundation-Dialysis Outcome Quality Initiative guidelines has generated a debate on the management of advanced renal failure and the role of low-protein diets (LPDs). We performed a review of the literature to identify articles on the initiation of dialysis and LPDs, particularly those since 1996. Delayed referral of patients is widespread in both the United States and Europe, and almost 25% of patients are started on dialysis at a glomerular filtration rate (GFR) of <5 mL/min/1.73 m2. There is a high prevalence of malnutrition at the time of first dialysis, which progressively improves upon initiation of dialysis. There is no evidence regarding the efficacy or safety of LPDs in nondiabetic patients younger than 70 years old [approximately 40% of U.S. incident end-stage renal disease (ESRD) patients] and in diabetics with GFR <25 mL/min/1.73 m2 (>40% of incident U.S. ESRD). In nondiabetics who are younger than 70 years old, adherence to LPD for four to five years can be estimated to result in a delay in dialysis by 6 to 11 months. However, suboptimal energy intake is widespread in advanced renal failure, which declines further upon institution of LPD. Even nutritionally sound patients develop subclinical nutritional decline despite intense counseling. There are no data on the efficacy or safety of LPD in subgroups that constitute approximately 80% of incident ESRD patients. Concerns still exist regarding their nutritional safety in the remainder. Initiation of dialysis results in improved nutritional status and should be considered in a timely fashion.
Ethier I, Cho Y, Hawley C, Pascoe EM, Viecelli AK, Campbell SB, van Eps C, Isbel NM, Cooper BA, Harris DC, Pollock CA, Wong MG, Johnson DW.
Rate of decline in residual kidney function pre and post peritoneal dialysis initiation: A post hoc analysis of the IDEAL study.
PLoS One. 2020;15(11):e0242254. doi: 10.1371/journal.pone.0242254. Epub 2020 Nov 16.
Abstract/Text
BACKGROUND: Residual kidney function (RKF) is associated with improved survival and quality of life in dialysis patients. Previous studies have suggested that initiation of peritoneal dialysis (PD) may slow RKF decline compared to the pre-dialysis period. We sought to evaluate the association between PD initiation and RKF decline in the Initiating Dialysis Early And Late (IDEAL) trial.
METHODS: In this post hoc analysis of the IDEAL randomized controlled trial, PD participants were included if results from 24-hour urine collections had been recorded within 30 days of dialysis initiation, and at least one value pre- and one value post-dialysis commencement were available. The primary outcome was slope of RKF decline, calculated as mean of urinary creatinine and urea clearances. Secondary outcomes included slope of urine volume decline and time from PD initiation to anuria.
RESULTS: The study included 151 participants (79 early start, 72 late start). The slope of RKF decline was slower after PD initiation (-2.69±0.18mL/min/1.73m2/yr) compared to before PD (-4.09±0.33mL/min/1.73m2/yr; change in slope +1.19 mL/min/1.73m2/yr, 95%CI 0.48-1.90, p<0.001). In contrast, urine volume decline was faster after PD commencement (-0.74±0.05 L/yr) compared to beforehand (-0.57±0.06L/yr; change in slope -0.18L/yr, 95%CI -0.34--0.01, p = 0.04). No differences were observed between the early- and late-start groups with respect to RKF decline, urine volume decline or time to anuria.
CONCLUSIONS: Initiation of PD was associated with a slower decline of RKF compared to the pre-dialysis period.
.
Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group.
J Am Soc Nephrol. 1996 Feb;7(2):198-207. doi: 10.1681/ASN.V72198.
Abstract/Text
The objective of the study presented here was to evaluate the relationship of adequacy of dialysis and nutritional status to mortality, technique failure, and morbidity. This was a prospective cohort study of consecutive patients commencing continuous peritoneal dialysis in 14 centers in Canada and the United States. Between September 1, 1990 and December 31, 1992, 680 patients were enrolled. Follow-up was terminated December 31, 1993. There were 90 deaths, 137 transplants, and 118 technique failures. Fifteen withdrew from dialysis. Analysis of the patient and technique survival used the Cox proportional hazards model with adequacy of dialysis and nutritional status as time-dependent covariates. The relative risk (RR) of death increased with increased age, insulin-dependent diabetes mellitus, cardiovascular disease, decreased serum albumin concentration and worsened nutritional status (subjective global assessment and percentage lean body mass). A decrease of 0.1 unit Kt/V per week was associated with a 5% increase in the RR of death; a decrease of 5 L/1.73 m2 creatinine clearance (CCr) per week was associated with a 7% increase in the RR of death. The RR of technique failure was increased with decreased albumin concentration and decreased CCr. Hospitalization was increased with decreased serum albumin concentration, worsened nutrition according to subjective global assessment and decreased CCr. A weekly Kt/V of 2.1 and a weekly CCr of 70 L/1.73 m2 were each associated with an expected 2-yr survival of 78%.
Jain AK, Sontrop JM, Perl J, Blake PG, Clark WF, Moist LM.
Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry.
Am J Kidney Dis. 2014 May;63(5):798-805. doi: 10.1053/j.ajkd.2013.10.054. Epub 2013 Dec 12.
Abstract/Text
BACKGROUND: Several observational studies of hemodialysis patients show an association between early dialysis therapy initiation and increased mortality. Few studies have examined this association among peritoneal dialysis patients.
STUDY DESIGN: Retrospective cohort study.
SETTING & PARTICIPANTS: A cohort of 8,047 incident peritoneal dialysis patients who started dialysis therapy in 2001-2009 and were treated in Canada.
PREDICTOR: Estimated glomerular filtration rate (eGFR) at dialysis therapy initiation. Defined early, mid, and late starts as eGFR>10.5, 7.5-10.5, and <7.5mL/min/1.73m(2), respectively.
OUTCOMES: Time to death.
MEASUREMENTS: Proportional piecewise exponential survival models to compare mortality (overall and early) for the 3 predictor groups.
RESULTS: Between 2001 and 2009, the proportion of patients starting peritoneal dialysis therapy as early starts increased from 29% (95% CI, 26%-32%) to 44% (95% CI, 41%-47%). Compared with the late-start group, the overall mortality rate was not higher for the early- (adjusted HR, 1.08; 95% CI, 0.96-1.23) or mid-start (adjusted HR, 0.96; 95% CI, 0.86-1.09) groups. However, when examined yearly, patients in the early-start group were significantly more likely to die within the first year of dialysis therapy compared with those in the late-start group (adjusted HR, 1.38; 95% CI, 1.10-1.73), but not in subsequent years.
LIMITATIONS: Bias and residual confounding may have influenced the observed relationship between predictor and outcome.
CONCLUSIONS: Patients are initiating peritoneal dialysis therapy at increasingly higher eGFRs. Contrary to most observational studies assessing hemodialysis, the early initiation of peritoneal dialysis therapy, at eGFR>10.5mL/min/1.73m(2), is not associated with increased mortality.
Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Kim HW, Kim SH, Kim YO, Jin DC, Song HC, Choi EJ, Kim YL, Kim YS, Kang SW, Kim NH, Yang CW, Kim YK.
The Impact of Timing of Dialysis Initiation on Mortality in Patients with Peritoneal Dialysis.
Perit Dial Int. 2015 Dec;35(7):703-11. doi: 10.3747/pdi.2013.00328. Epub 2014 Oct 7.
Abstract/Text
UNLABELLED: ♦
BACKGROUND: The impact of timing of dialysis initiation on mortality is controversial in patients with peritoneal dialysis (PD). In this study, we analyzed the impact of timing of dialysis initiation on mortality in the incident PD population. ♦
METHODS: Incident patients with PD were selected from the Clinical Research Center (CRC) registry for end-stage renal disease (ESRD), a prospective cohort study on dialysis in Korea. Patients were categorized into 3 groups according to the estimated glomerular filtration rate (eGFR) at the initiation of PD using the Modification of Diet in Renal Disease (MDRD) equation. Group A was defined as eGFR < 5 mL/min/1.73m(2), group B as eGFR 5 - 10 mL/min/1.73m(2), and group C as eGFR > 10 mL/min/1.73m(2). Cox regression analysis was used to calculate the adjusted hazard ratio (HR) of mortality with group B as the reference. The primary outcome was all-cause mortality. ♦
RESULTS: A total of 495 incident PD patients were included. The number of patients in group A was 109, group B was 279, and group C was 107. The median follow-up period was 23 months. Multivariate Cox regression analysis showed that group A had a significantly higher risk of all-cause mortality compared with group B (HR 4.13, 95% confidence interval [CI], 1.55 - 11.03, p = 0.005) after adjustment for age, gender, cause of ESRD, serum albumin level, diabetes mellitus, and cardiovascular disease. There was no significant difference in mortality between group C and group B (HR 1.50, 95% CI, 0.59 - 3.80, p = 0.398) after adjustment for clinical variables. ♦
CONCLUSION: An eGFR < 5 mL/min/1.73m(2) at the initiation of PD was a significant risk factor for death, while an eGFR >10 mL/min/1.73m(2) at the initiation of PD was not associated with improved survival compared with an eGFR of 5 - 10 mL/min/1.73m(2) at the initiation of PD.
Copyright © 2015 International Society for Peritoneal Dialysis.
Johnson DW, Wong MG, Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA.
Effect of timing of dialysis commencement on clinical outcomes of patients with planned initiation of peritoneal dialysis in the IDEAL trial.
Perit Dial Int. 2012 Nov-Dec;32(6):595-604. doi: 10.3747/pdi.2012.00046.
Abstract/Text
BACKGROUND: Since the mid-1990s, early dialysis initiation has dramatically increased in many countries. The Initiating Dialysis Early and Late (IDEAL) study demonstrated that, compared with late initiation, planned early initiation of dialysis was associated with comparable clinical outcomes and increased health care costs. Because residual renal function is a key determinant of outcome and is better preserved with peritoneal dialysis (PD), the present pre-specified subgroup analysis of the IDEAL trial examined the effects of early-compared with late-start dialysis on clinical outcomes in patients whose planned therapy at the time of randomization was PD.
METHODS: Adults with an estimated glomerular filtration rate (eGFR) of 10 - 15 mL/min/1.73 m(2) who planned to be treated with PD were randomly allocated to commence dialysis at an eGFR of 10 - 14 mL/min/1.73 m(2) (early start) or 5 - 7 mL/min/1.73 m(2) (late start). The primary outcome was all-cause mortality.
RESULTS: Of the 828 IDEAL trial participants, 466 (56%) planned to commence PD and were randomized to early start (n = 233) or late start (n = 233). The median times from randomization to dialysis initiation were, respectively, 2.03 months [interquartile range (IQR):1.67 - 2.30 months] and 7.83 months (IQR: 5.83 - 8.83 months). Death occurred in 102 early-start patients and 96 late-start patients [hazard ratio: 1.04; 95% confidence interval (CI): 0.79 - 1.37]. No differences in composite cardiovascular events, composite infectious deaths, or dialysis-associated complications were observed between the groups. Peritonitis rates were 0.73 episodes (95% CI: 0.65 - 0.82 episodes) per patient-year in the early-start group and 0.69 episodes (95% CI: 0.61 - 0.78 episodes) per patient-year in the late-start group (incidence rate ratio: 1.19; 95% CI: 0.86 - 1.65; p = 0.29). The proportion of patients planning to commence PD who actually initiated dialysis with PD was higher in the early-start group (80% vs 70%, p = 0.01).
CONCLUSION: Early initiation of dialysis in patients with stage 5 chronic kidney disease who planned to be treated with PD was associated with clinical outcomes comparable to those seen with late dialysis initiation. Compared with early-start patients, late-start patients who had chosen PD as their planned dialysis modality were less likely to commence on PD.
日本腎臓学会編：エビデンスに基づくCKD診療ガイドライン2023、東京医学社、2023.
Kazmi WH, Obrador GT, Khan SS, Pereira BJ, Kausz AT.
Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis.
Nephrol Dial Transplant. 2004 Jul;19(7):1808-14. doi: 10.1093/ndt/gfg573.
Abstract/Text
BACKGROUND: Late nephrology referral has been associated with adverse outcomes among patients with end-stage renal disease; however, its relationship to mortality is unclear. We examined the impact of timing of nephrology care relative to initiation of dialysis on mortality after initiation of dialysis.
METHODS: Data from the Dialysis Morbidity and Mortality Study - Wave II, a prospective study of incident dialysis patients, were used. Late referral (LR) was defined as first nephrology visit <4 months and early referral (ER) as first nephrology visit >or=4 months prior to initiation of dialysis. Propensity scores (PS) were estimated using logistic regression to predict the probability that a given patient was LR. A Cox proportional hazards model was built to examine the association between timing of nephrology referral and mortality.
RESULTS: The cohort was comprised of 2195 patients: 54% were males, 66% were Caucasians, 26% were African-Americans and 33% were referred late. A Cox proportional hazards analysis demonstrated that compared with ER patients, LR patients had a 44% higher risk of death at 1 year after initiation of dialysis [hazards ratio (HR) = 1.44; 95% confidence interval (CI): 1.15-1.80], which remained significant after adjusting for quintiles of PS (HR = 1.42; 95% CI: 1.12-1.80).
CONCLUSIONS: Among patients with chronic kidney disease (CKD) who initiated dialysis, LR was associated with higher risk of death at 1 year after initiation of dialysis compared with ER.
Roderick P, Jones C, Drey N, Blakeley S, Webster P, Goddard J, Garland S, Bourton L, Mason J, Tomson C.
Late referral for end-stage renal disease: a region-wide survey in the south west of England.
Nephrol Dial Transplant. 2002 Jul;17(7):1252-9. doi: 10.1093/ndt/17.7.1252.
Abstract/Text
BACKGROUND: The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT.
METHODS: Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as 'late' if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT.
RESULTS: One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups.
CONCLUSION: Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1-4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.
Orlando LA, Owen WF, Matchar DB.
Relationship between nephrologist care and progression of chronic kidney disease.
N C Med J. 2007 Jan-Feb;68(1):9-16.
Abstract/Text
BACKGROUND: Since chronic kidney disease (CKD) affects 11% of the United States population, and its incidence is rising, experts recommend early referral to nephrologists in the hope that it may delay the onset of end-stage disease and improve survival. However, limitations in the capacity of currently practicing nephrologists may prevent widespread early referral.
OBJECTIVE: To examine the relationship between disease progression and timing of nephrology referral.
STUDY DESIGN AND DATA COLLECTION: We retrospectively identified 1,553 veterans at the Durham, North Carolina VA hospital between January 1998 and December 1999 who had CKD, defined as two outpatient serum creatinines > or = 1.4 mg/dL at least three months apart. Our endpoint was a composite of progression to the next CKD stage or death. We compared the time to the composite endpoint for each CKD stage and for early CKD (stages 1-3) to advanced CKD (stages 4 and 5) using a Cox proportional hazards model for two groups: those with primary care only (PCP-only) and those with primary and nephrology care (nephrology).
RESULTS: Ninety-two percent had hypertension, 52% diabetes, 49% coronary artery disease, and 89% proteinuria. Angiotensin-converting enzyme inhibitors and anti-lipid medications were used by 52% and 39%, respectively. The median number of days spent in each CKD stage and the proportion of each groups reaching the composite endpoint are--stage 1: 1,149 days, 68% of the PCP-only group and 73% of the nephrology group; stage 2: 1,206 days, 60% and 65%; stage 3: 1,158 days, 69% and 63%; and stage 4: 794 days, 86% and 72%. Adjusted survival curves for the composite endpoint were similar between the two groups for CKD stages 1 (HR 1.08 for nephrology versus PCP-only) and 2 (HR 1.20); however for CKD stages 3 (HR 0.80, p < 0.05) and 4 (HR 0.75, p < 0.05), the nephrology group gained 316, 215, and 120 more days of progression-free survival, respectively.
LIMITATIONS: The major limitation is difficulty accounting for unmeasured bias in specialty referrals. We were unable to analyze stage 5-to-dialysis due to the small number of individuals with the outcome.
CONCLUSION: Our data suggest that an appropriate time for nephrology comanagement of patients with CKD may be stage 3; however, prospective studies are needed to clarify the role and timing of nephrology referral.
Fischer MJ, Stroupe KT, Kaufman JS, O'Hare AM, Browning MM, Sohn MW, Huo Z, Hynes DM.
Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis.
BMC Nephrol. 2016 Jul 29;17(1):103. doi: 10.1186/s12882-016-0324-5. Epub 2016 Jul 29.
Abstract/Text
BACKGROUND: Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known.
METHODS: Retrospective cohort study of patients ≥66 years who initiated chronic dialysis in 2000-2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3-6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes.
RESULTS: Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p < 0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65-0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42-3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77-0.82).
CONCLUSION: In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.
Nakamura S, Nakata H, Yoshihara F, Kamide K, Horio T, Nakahama H, Kawano Y.
Effect of early nephrology referral on the initiation of hemodialysis and survival in patients with chronic kidney disease and cardiovascular diseases.
Circ J. 2007 Apr;71(4):511-6. doi: 10.1253/circj.71.511.
Abstract/Text
BACKGROUND: The timing of referral to nephrologists is highly variable in patients with chronic kidney disease (CKD). The impact of early referral on the timing of hemodialysis (HD) and mortality in the patients with CKD and cardiovascular diseases (CVD) was evaluated in this present study.
METHODS AND RESULTS: A total of 366 patients with CKD and CVD began HD at the National Cardiovascular Center between 1983 and 2003, and survival was followed until 2005. The times between the first evaluation by a nephrologist and the date of the first HD were categorized as late (LR <6 months) or early (ER > or =6 months) referral. Patients were classified into the ER (n=194) and LR (n=172) groups. Clinical data and renal function were not different. In the LR group, the renal function declined more rapidly and the duration between the first visit to the hospital and the first HD was shorter than the ER group. The survival rate after the initiation of HD was better in the ER group. Age, pre end-stage renal disease therapy and cardiac function had a significant impact on survival.
CONCLUSIONS: Early nephrology referral is important and necessary for for patients with CKD and CVD in terms of a better renal prognosis and survival.
Baek SH, Ahn Sy, Lee SW, Park YS, Kim S, Na KY, Chae DW, Kim S, Chin HJ.
Outcomes of predialysis nephrology care in elderly patients beginning to undergo dialysis.
PLoS One. 2015;10(6):e0128715. doi: 10.1371/journal.pone.0128715. Epub 2015 Jun 1.
Abstract/Text
BACKGROUND: The proportion of elderly patients beginning to undergo dialysis is increasing globally. Whether early referral (ER) of elderly patients is associated with favorable outcomes remains under debate. We investigated the influence of referral timing on the mortality of elderly patients.
METHODS: We retrospectively assessed mortality in 820 patients aged ≥70 years with end-stage renal disease (ESRD) who initiated hemodialysis at a tertiary university hospital between 2000 and 2010. Mortality data was obtained from the time of dialysis initiation until December 2010. We assigned patients to one of two groups according to the time of their first encounters with nephrologists: ER (≥ 3 months) and late referral (LR; < 3 months).
RESULTS: During a mean follow-up period of 25.1 months, the ER group showed a 24% reduced risk of long-term mortality relative to the LR group (HR = 0.760, P = 0.009). Rate of reduction in 90-day mortality for ER patients was 58% (HR = 0.422, P=0.012). However, the statistical significance of the difference in mortality rates between ER and LR group was not observed across age groups after 90 days. Old age, LR, central venous catheter, high white blood cell count and corrected Ca level, and lower levels of albumin, creatinine, hemoglobin, and sodium were significantly associated with increased risk of mortality.
CONCLUSIONS: Timely referral was also associated with reduced mortality in elderly ESRD patients who initiated hemodialysis. In particular, the initial 90-day mortality reduction in ER patients contributed to mortality differences during the follow-up period.
日本臨床腎移植学会・日本移植学会 生体腎移植ドナーガイドライン策定合同委員会：生体腎移植のドナーガイドライン, 2014.
日本臨床腎移植学会・日本移植学会：腎移植臨床登録集計報告（2021）2020年実施症例の集計報告と追跡調査結果.移植 2021；56：185-216.
日本臨床腎移植学会・日本移植学会：腎移植臨床登録集計報告（2016）2015年実施症例の集計報告と追跡調査結果．移植 2016；51：124‒144.
Abecassis M, Bartlett ST, Collins AJ, Davis CL, Delmonico FL, Friedewald JJ, Hays R, Howard A, Jones E, Leichtman AB, Merion RM, Metzger RA, Pradel F, Schweitzer EJ, Velez RL, Gaston RS.
Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference.
Clin J Am Soc Nephrol. 2008 Mar;3(2):471-80. doi: 10.2215/CJN.05021107. Epub 2008 Feb 6.
Abstract/Text
BACKGROUND AND OBJECTIVES: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy.
RESULTS: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers.
CONCLUSIONS: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.
日本移植学会広報委員会：臓器移植ファクトブック2020 日本移植学会, 2020.
中井滋, 政金生人, 秋葉隆ほか: わが国の慢性透析療法の現況(2005年12月31日現在). 日本透析医学会雑誌 40: 1-30, 2013.
政金生人, 中井滋, 尾形聡ほか: わが国の慢性透析療法の現況(2014 年12月31日現在). 日本透析医学会雑誌 49(1) : 1-34, 2016.
Foley RN, Herzog CA, Collins AJ; United States Renal Data System.
Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.
Kidney Int. 2002 Nov;62(5):1784-90. doi: 10.1046/j.1523-1755.2002.00636.x.
Abstract/Text
BACKGROUND: The long-term prognostic associations of pre- and post-dialysis blood pressures, interdialytic weight gain, and antihypertensive use in hemodialysis patients are unclear.
METHODS: The United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Waves 3 and 4 Study, a randomly generated sample of 11,142 subjects receiving hemodialysis on December 31, 1993, was examined, with vital status followed until May 2000.
RESULTS: Pre- and post-dialysis blood pressure values, interdialytic weight gain and number of antihypertensives averaged 151.8/79.7, 137.0/74, 3.6% and 0.76, respectively. Prognostic discrimination was maximized by considering pre- and post-systolic and diastolic blood pressure values simultaneously, in a pattern suggesting that wide pulse pressures were associated with mortality (P < 0.0001). Comorbidity adjustment markedly affected associations, with low pre-dialysis diastolic (P < 0.05), low post-dialysis dialysis diastolic pressure (P < 0.05), high post-dialysis dialysis systolic pressure (P < 0.05), and high interdialytic weight gains (P = 0.005) associated with mortality. Each class of antihypertensive drug, except angiotensin-converting enzyme (ACE)-inhibitors, was associated with lower mortality in unadjusted models, an effect most pronounced for beta-blockers (hazards ratio 0.72, 95% CI 0.66 to 0.79, P < 0.0001). Comorbidity adjustment eliminated survival associations for each antihypertensive class except beta-blockers.
CONCLUSIONS: Pre- and post-dialysis blood pressure values have independent associations with mortality, in a way that implicates wide pulse pressures. Much of the adverse prognosis of wide pulse pressures probably reflects older age and cardiovascular comorbidity. Large interdialytic weight gains are associated with shorter survival when comorbidity is taken into account. Beta-blocker use shows a robust association with survival, and may be protective.
平方秀樹, 新田孝作, 友雅司ほか: 社団法人日本透析医学会 血液透析患者における心血管合併症の評価と治療に関するガイドライン. 日本透析医学会雑誌 44: 337-425, 2011.
中尾俊之, 菅野義彦, 長澤康行ほか. 慢性透析患者の食事療法基準. 日本透析医学会雑誌 47(5): 287-291, 2014.
平田純生,和泉 智,古久保 拓. 透析患者への投薬ガイドブック 改訂2版―慢性腎臓病(CKD)の薬物治療. じほう, 東京, 2009．.
日本腎臓学会編. CKD診療ガイド2012. 東京医学社, 東京, 2012.
日本腎臓学会・日本医学放射線学会・日本循環器学会編：腎障害患者におけるヨード造影剤使用に関するガイドライン2012. 東京医学社, 東京, 2012.
Maruyama T, Takashima H, Abe M.
Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis.
Expert Opin Pharmacother. 2020 Jul;21(10):1219-1240. doi: 10.1080/14656566.2020.1746272. Epub 2020 Apr 13.
Abstract/Text
INTRODUCTION: Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking.
AREAS COVERED: The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including 'hypertension', 'pharmacotherapy', 'dialysis', 'kidney disease', and 'antihypertensive drug'. Systematic and narrative reviews and original investigations were retrieved in our research.
EXPERT OPINION: When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.
2015年版 慢性腎臓病患者における腎性貧血治療のガイドライン. 透析会誌 2016; 49(2): 89-158.
社団法人日本透析医学会．慢性腎臓病に伴う骨・ミネラル代謝異常の診療ガイドライン．日透析医学会誌2012；45：301-356.
Inaba M, Okuno S, Kumeda Y, Yamada S, Imanishi Y, Tabata T, Okamura M, Okada S, Yamakawa T, Ishimura E, Nishizawa Y; Osaka CKD Expert Research Group.
Glycated albumin is a better glycemic indicator than glycated hemoglobin values in hemodialysis patients with diabetes: effect of anemia and erythropoietin injection.
J Am Soc Nephrol. 2007 Mar;18(3):896-903. doi: 10.1681/ASN.2006070772. Epub 2007 Jan 31.
Abstract/Text
The significance of glycated albumin (GA), compared with casual plasma glucose (PG) and glycated hemoglobin (HbA(1c)), was evaluated as an indicator of the glycemic control state in hemodialysis (HD) patients with diabetes. The mean PG, GA, and HbA(1c) levels were 164.5 +/- 55.7 mg/dl, 22.5 +/- 7.5%, and 5.85 +/- 1.26%, respectively, in HD patients with diabetes (n = 538), which were increased by 51.5, 31.6, and 17.7%, respectively, compared with HD patients without diabetes (n = 828). HbA(1c) levels were significantly lower than simultaneous PG and GA values in those patients in comparison with the relationship among the three parameters in patients who had diabetes without renal dysfunction (n = 365), as reflected by the significantly more shallow slope of regression line between HbA(1c) and PG or GA. A significant negative correlation was found between GA and serum albumin (r = -0.131, P = 0.002) in HD patients with diabetes, whereas HbA(1c) correlated positively and negatively with hemoglobin (r = 0.090, P = 0.036) and weekly dose of erythropoietin injection (r = -0.159, P < 0.001), respectively. Although PG and GA did not differ significantly between HD patients with diabetes and with and without erythropoietin injection, HbA(1c) levels were significantly higher in patients without erythropoietin. Categorization of glycemic control into arbitrary quartile by HbA(1c) level led to better glycemic control in a significantly higher proportions of HD patients with diabetes than those assessed by GA. Multiple regression analysis demonstrated that the weekly dose of erythropoietin, in addition to PG, emerged as an independent factor associated with HbA(1c) in HD patients with diabetes, although PG but not albumin was an independent factor associated with GA. In summary, it is suggested that GA provides a significantly better measure to estimate glycemic control in HD patients with diabetes and that the assessment of glycemic control by HbA(1c) in these patients might lead to underestimation likely as a result of the increasing proportion of young erythrocyte by the use of erythropoietin.
Abe M, Matsumoto K.
Glycated hemoglobin or glycated albumin for assessment of glycemic control in hemodialysis patients with diabetes?
Nat Clin Pract Nephrol. 2008 Sep;4(9):482-3. doi: 10.1038/ncpneph0881. Epub 2008 Jul 15.
Abstract/Text
This commentary discusses the findings of a study by Peacock et al., who measured levels of glycated hemoglobin (HbA(1c)) and glycated albumin in patients with diabetes who either were or were not on hemodialysis in an effort to determine which marker is the better indicator of glycemic control. They found that HbA(1c) and glycated albumin levels are both independently associated with serum glucose level. However, HbA(1c) level--unlike glycated albumin level--was also influenced by hemodialysis, hemoglobin level, and erythropoietin dose. Although we agree that glycated albumin level could be a better indicator of glycemic control than HbA(1c) level in patients on hemodialysis who have diabetes and anuria, this conclusion might not be applicable to patients with massive proteinuria or to those on peritoneal dialysis. Further studies are required to confirm the target glycated albumin level that is necessary to ensure a good prognosis for patients with diabetes who are on hemodialysis because no clear consensus has yet been reached. In addition, more data are needed to determine at which stage of kidney disease measurement of glycated albumin levels becomes preferable to assessment of HbA(1c) level.
稲葉雅章：血糖コントロール指標. 腎臓 2009; 32: 4-8.
日本透析医学会 血液透析患者の糖尿病治療ガイド2012.
Shima K, Komatsu M, Kawahara K, Minaguchi J, Kawashima S.
Stringent glycaemic control prolongs survival in diabetic patients with end-stage renal disease on haemodialysis.
Nephrology (Carlton). 2010 Sep;15(6):632-8. doi: 10.1111/j.1440-1797.2010.01273.x.
Abstract/Text
AIM: No suitable index or optimal target for diabetic control has been established for diabetic patients with end-stage renal disease (ESRD) undergoing haemodialysis. To address these issues, the single-centre observational study was conducted.
METHODS: Two hundred and forty-five diabetic ESRD patients (23.3% female; age at initiation of haemodialysis 61.7 ± 10.7 years) at start of haemodialysis between 1 January 1995 and 31 December 2004 were enrolled. Subjects were grouped according to glycaemic control level throughout the observational period as follows: mean postprandial plasma glucose (PPG) <8.9 mmol/L, 8.9 mmol/L ≤ PPG < 10.0 mmol/L, 10.0 mmol/L ≤ PPG < 11.1 mmol/L, 11.1 mmol/L ≤ PPG < 12.2 mmol/L and PPG ≥ 12.2 mmol/L; and HbA1c < 6.0%, 6.0-6.4%, 6.5-6.9% and ≥ 7.0%. Survival was then followed until 31 December 2005.
RESULTS: Cumulative survival of groups of 10.0 mmol/L ≤ PPG < 11.1 mmol/L, 11.1 ≤ PPG < 12.2 and PPG ≥ 12.2 mmol/L was significantly lower than that for PPG < 8.9 mmol/L as determined by Kaplan-Meier estimation (P = 0.016, 0.009 and 0.031, respectively; log-rank test). In both uni- and multivariate Cox proportional hazard models, mortality hazard ratios were significantly higher for PPG ≥ 10.0 mmol/L than for PPG < 8.9 mmol/L (P = 0.002-0.021). Kaplan-Meier survival curves grouped by HbA1c levels showed no correlation between HbA1c and survival during the observational period. No significant difference in mortality hazard ratios was seen for any HbA1c groups evaluated by Cox proportional hazard model.
CONCLUSION: Intensive management of diabetic control at a stringent mean on-study PPG < 10.0 mmol/L will improve the life expectancy in diabetic dialysis patients. However, no range of HbA1c values obtained in this study showed any clear difference in clinical outcomes.
© 2010 The Authors. Nephrology © 2010 Asian Pacific Society of Nephrology.
Ricks J, Molnar MZ, Kovesdy CP, Shah A, Nissenson AR, Williams M, Kalantar-Zadeh K.
Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study.
Diabetes. 2012 Mar;61(3):708-15. doi: 10.2337/db11-1015. Epub 2012 Feb 7.
Abstract/Text
Previous observational studies using differing methodologies have yielded inconsistent results regarding the association between glycemic control and outcomes in diabetic patients receiving maintenance hemodialysis (MHD). We examined mortality predictability of A1C and random serum glucose over time in a contemporary cohort of 54,757 diabetic MHD patients (age 63 ± 13 years, 51% men, 30% African Americans, 19% Hispanics). Adjusted all-cause death hazard ratio (HR) for baseline A1C increments of 8.0-8.9, 9.0-9.9, and ≥10%, compared with 7.0-7.9% (reference), was 1.06 (95% CI 1.01-1.12), 1.05 (0.99-1.12), and 1.19 (1.12-1.28), respectively, and for time-averaged A1C was 1.11 (1.05-1.16), 1.36 (1.27-1.45), and 1.59 (1.46-1.72). A symmetric increase in mortality also occurred with time-averaged A1C levels in the low range (6.0-6.9%, HR 1.05 [95% CI 1.01-1.08]; 5.0-5.9%, 1.08 [1.04-1.11], and ≤5%, 1.35 [1.29-1.42]) compared with 7.0-7.9% in fully adjusted models. Adjusted all-cause death HR for time-averaged blood glucose 175-199, 200-249, 250-299, and ≥300 mg/dL, compared with 150-175 mg/dL (reference), was 1.03 (95% CI 0.99-1.07), 1.14 (1.10-1.19), 1.30 (1.23-1.37), and 1.66 (1.56-1.76), respectively. Hence, poor glycemic control (A1C ≥8% or serum glucose ≥200 mg/dL) appears to be associated with high all-cause and cardiovascular death in MHD patients. Very low glycemic levels are also associated with high mortality risk.
Okada T, Nakao T, Matsumoto H, Shino T, Nagaoka Y, Tomaru R, Wada T.
Association between markers of glycemic control, cardiovascular complications and survival in type 2 diabetic patients with end-stage renal disease.
Intern Med. 2007;46(12):807-14. doi: 10.2169/internalmedicine.46.6355. Epub 2007 Jun 15.
Abstract/Text
BACKGROUND AND OBJECTIVE: The influence of glycemic control on cardiovascular (CV) complications or survival is not clear in diabetic patients with end-stage renal disease (ESRD). Although glycohemoglobin (HbA1c) is widely used as a marker of hyperglycemia in these patients, it may be unreliable because of shortened erythrocyte lifespan. Glycated albumin (GA) is an alternative marker. We investigated the relation between these markers and development of CV complications or survival in diabetic ESRD patients.
PATIENTS AND METHODS: We obtained three variables as markers of glycemic control: 1) mean HbA1c levels during 1-year after initiation of dialysis (HbA1c1), 2) mean HbA1c levels during 3 months from August to October 2002 (HbA1c2), 3) GA on October 2002 (GA2) from 78 type 2 diabetic patients on chronic hemodialysis. We examined the influence of these variables on survival or development of CV diseases using the multivariate Cox proportional-hazards models until September 2006.
RESULTS: The 3-year survival rate was 73%. A total of 27 patients died, 15 from CV diseases. A total of 23 CV diseases developed in 20 patients. Neither HbA1c1 nor HbA1c2 was associated with all-cause mortality, CV mortality or development of CV diseases. GA2 was also not associated with mortality. However, the higher GA2 group (GA > or = 23.0%) had a significantly higher rate of development of CV diseases than the lower GA2 group (GA < 23.0%) (log-rank test p=0.03). The higher GA2 group was significantly associated with development of CV diseases relative to the lower GA2 group (hazard ratio 3.25, p=0.04).
CONCLUSION: Neither HbA1c levels nor GA levels, at initiation of dialysis or on chronic dialysis, predicted mortality in diabetic ESRD patients. However, poor glycemic control as reflected by higher GA levels may be associated with the development of CV diseases. More studies are needed to clarify the beneficial effect of glycemic control in these patients.
Isshiki K, Nishio T, Isono M, Makiishi T, Shikano T, Tomita K, Nishio T, Kanasaki M, Maegawa H, Uzu T; Lake Biwa Clinical Dialysis Meeting.
Glycated albumin predicts the risk of mortality in type 2 diabetic patients on hemodialysis: evaluation of a target level for improving survival.
Ther Apher Dial. 2014 Oct;18(5):434-42. doi: 10.1111/1744-9987.12123. Epub 2013 Nov 20.
Abstract/Text
Glycated albumin (GA) is considered a more reliable marker than glycated hemoglobin (HbA1c) for monitoring glycemic control, particularly in diabetic hemodialysis patients. We investigated the associations of GA, HbA1c, and random serum glucose levels with survival, and evaluated possible targets for improving survival in diabetic hemodialysis patients. In this prospective, longitudinal, observational study, we enrolled 90 diabetic hemodialysis patients across six dialysis centers in Japan. The median duration of follow-up was 36.0 months (mean follow-up, 29.8 months; range, 3-36 months). There were 11 deaths during the observation period. GA was a significant predictor for mortality (hazard ratio, 1.143 per 1% increase in GA; 95% confidence interval, 1.011-1.292; P = 0.033), whereas HbA1c and random glucose levels were not predictors for mortality. Receiver operating characteristics curve analysis showed that the cutoff value of GA for predicting the risk of mortality was 25%. In the Kaplan-Meier analysis, the cumulative survival rate was significantly greater in patients with GA ≤ 25% than in patients with GA >25%. GA predicted the risk of all-cause and cardiovascular mortality in diabetic hemodialysis patients. Our results suggest that GA ≤ 25% is an appropriate target for improving survival in diabetic hemodialysis patients.
© 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.
Inaba M, Maekawa K, Okuno S, Imanishi Y, Hayashino Y, Emoto M, Shoji T, Ishimura E, Yamakawa T, Nishizawa Y.
Impact of atherosclerosis on the relationship of glycemic control and mortality in diabetic patients on hemodialysis.
Clin Nephrol. 2012 Oct;78(4):273-80. doi: 10.5414/CN106940.
Abstract/Text
OBJECTIVE: The impact of preexisting cardiovascular disease (CVD) on glycemic control-improved survival in hemodialysis patients with diabetes mellitus (DM) was investigated. Glycoalbumin (GA) was used as a glycemic marker.
METHODS: A single-center 4-year follow-up study was performed in an observational cohort of 178 DM hemodialysis patients to analyze the relationship between GA and all-cause mortality in patients with (n = 70) and without (n = 108) CVD. The subjects were divided into three categories based on GA value at the start of study.
RESULTS: Baseline characteristics did not differ between the two groups of patients. During the 4-year follow-up, 24 of 108 (23.3%) CVD(-) patients and 30 of 70 (42.8%) CVD(+) patients died. The mortality was significantly higher in the CVD(+) group. Multivariate Cox analyses including GA, logCRP, age, gender, hemodialysis duration, albumin, hemoglobin, BMI, SBP, DBP, smoking habit, and SUN as independent variables showed that GA, in addition to logCRP and age, was independently associated with mortality in all patients. Kaplan-Meier analysis showed lower GA levels to be a significant predictor of lower mortality in the CVD(-) group, but not in the CVD(+) group. Multivariable-adjusted Cox proportional hazards models demonstrated a significant association between GA with allcause mortality risk in the CVD(-) group (p = 0.004), in contrast with the CVD(+) group in the same model (p = 0.842).
CONCLUSION: These results demonstrate a beneficial effect of improved glycemic control on survival in DM hemodialysis patients, which might be attenuated by the presence of CVD.
岡田一義：血液透析診療指針 東京医学社, 東京, 2021.
