Dialysis and Mortality: Does It Matter Where You Live?

[摘要] A 70-year-old man with diabetic nephropathy and a history of multiple admissions for congestive heart failure is approaching the need for renal replacement therapy. He is struggling with his decision regarding the optimal dialysis modality. He lives alone in rural Washington, 60 miles from the nearest dialysis unit. He is a man of modest means and cannot afford the transportation costs associated with thrice weekly in-center hemodialysis. Given his less than optimal prior compliance with his complex medical regimen, he is a risky candidate for peritoneal or home hemodialysis. Due to transportation issues, he decides that peritoneal dialysis is his only viable option. Does geography impact on patient survival? Clinicians usually do not consider a patient’s residence when making clinical decisions, but epidemiologic evidence has shown that patient characteristics, health services, and patient outcomes vary significantly according to rural versus urban residence. These geographic differences also exist within urban areas depending on residential characteristics. Rural America represents approximately 20% of the US population and is comprised of diverse cultures, landscapes, and economic and social characteristics. In 2005 the Institute of Medicine report, Quality through Collaboration: The Future of Rural Health Care, was released with the goal of providing an independent assessment of health and health care in rural America and formulating an action plan for quality-focused rural community health systems (1). The report highlighted a number of important issues in rural America including reduced access to quality health services, poor access to quality emergency services, and adverse patient characteristics such as higher rates of obesity, suicide, alcohol and tobacco use, poverty, and inferior treatment for acute myocardial infarction. These factors are of importance to rural patients with CKD and could represent major barriers to quality renal and general medical care.

[学科分类] 泌尿医学

[关键词] Bone marrow necrosis;Sickle cell disease;Hyperhemolysis syndrome