당뇨병성 만성 신장병 환자에서 신장내과 전과 시기가 예후에 미치는 영향 = The Impact of Timing of Nephrology Referral on Prognosis in Patients with Diabetic Chronic Kidney Disease

다국어 초록 (Multilingual Abstract)

Purpose:Diabetic patients with chronic kidney disease (CKD) are associated with a significantly poorer prognosis following renal replacement therapy (RRT) in comparison to those with nondiabetic CKD. To improve such prognosis, it is crucial to achieve a timely referral to nephrologists. This article evaluated the impact the timing of nephrology referral has on prognosis in patients with diabetic CKD.
Methods:Retrospective study was conducted regarding 239 patients with diabetic CKD on RRT. Patients were grouped according to referral patterns with those referred more than 1 month prior to initiating dialysis designated as early referral (ER) group and those referred within 1 month as late referral (LR) group. Characteristics of patients and risk factors for 3-month and 1-year mortality were analyzed, and mortality rates of ER and LR groups were compared using Kaplan-Meier curves of 1- year mortality.
Results:LR group showed a significantly higher (p=0.023) 1-year mortality rate and more frequently required urgent dialysis or angiocatheter and complicated congestive heart failure (CHF), pulmonary edema. Contrarily, ER group showed a significantly lower mortality rate (p=0.0179) based on Kaplan- Meier survival curve of 1-year mortality. According to logistic regression analysis, CVD (OR=7.695) and low total cholesterol level (OR=0.979) and CVD (OR=8.021), emergent dialysis (OR=3.734), and high HbA1C level (OR=1.528) were risk factors of significance of 3-month and 1-year mortality, respectively.
Conclusion:Among diabetic patients with CKD, late-referred group was associated with a significantly higher rate of 1-year mortality. With LR as a risk factor of 1-year mortality according to univariate analysis, timing of referral is a critical prognostic factor.

국문 초록 (Abstract)

목 적:당뇨병성 만성 신장병 환자에서의 투석 후 예후는 비당뇨병성 만성 신장병 환자에 비해 현저히 나쁘다. 예후를 향상시키기 위해서는 적기에 신장전문의에게 환자를 의뢰하고 적절한 시기에 신대체 요법을 시행 받는 것이 중요하다. 이에 본 연구자는 당뇨병성 만성 신장병으로 신대체 요법을 시행 받았던 환자들에서 신장내과 전과 시점이 환자의 예후에 미치는 영향을 알기 위해 이 연구를 계획하였다.
방 법:신대체 요법을 시작한 당뇨병성 만성 신장병 환자 239명을 대상으로 하였다. 환자군을 신장내과의뢰부터 신대체 요법까지 기간 1개월을 기준으로 조기와 후기 전과군 그리고 신장내과 의뢰 당시 만성신장병 단계의 2가지 기준으로 분류하였다. 환자군의 역학적 및 임상적 특징과 3개월과 1년 사망의 위험인자를 분석하였고 1년 Kaplan-Meier 생존곡선으로 조기와 후기 전과군의 생존률을 비교하였다.
결 과:후기 전과군이 1년 사망률이 의미 있게 높았으며 (p=0.023), 응급투석과 혈관도관 사용이 많았고 심부전, 폐부종 등 유병질환이 많았다. 1년 Kaplan-Meier 생존곡선에서 후기 전과군이 의미 있게 낮은 생존률을 보였다 (p=0.0179). 로지스틱 회귀분석에서 3개월 사망 위험인자는 뇌혈관질환 (OR=7.695), 낮은 총콜레스테롤 (OR=0.979)이 었고 1년 사망 위험인자는 뇌혈관질환 (OR=8.021), 응급투석 (OR=3.734), 높은 당화혈색소 (OR=1.528), 고령 (OR=1.081)이었다.
결 론:당뇨병성 만성 신장병 환자에서 후기 전과군의 1년 사망률이 의미 있게 높았고 단변량 분석에서 1년 사망위험인자이므로 전과 시기는 중요한 예후 인자이다. 또한 후기 전과군에서 응급투석과 혈관도관 사용이 많고 심부전과 폐부종 같은 유병질환이 많기 때문에 적절한 시기에 신장내과로 의뢰하는 것이 중요하다.

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