Ravani Pietro, Marinangeli Giancarlo, Stacchiotti Lorella, Malberti Fabio
Division of Nephrology and Dialysis, Cremona Hospital, Cremona, Italy.
J Nephrol. 2003 Nov-Dec;16(6):862-9.
Patients who begin chronic dialysis within 3 months of seeing a nephrologist (late referral)have increased morbidity and mortality. However, it is not known whether formal pre-dialysis education programs (PEPs) are more advantageous, regarding early dialysis outcomes and resource use, than unstructured specialist follow-up.
We prospectively collected information on specialist care, unstructured or PEP, modality choice and hospitalizations in the 1st 3 months of dialysis for all consecutive patients who started dialysis between 1st January 1999 and 30th June 2002 in two Italian centers.
The 229 patients who participated in this study (62% male, median age 70 yrs) had a high prevalence of diabetes (27.5%) and cardiovascular disease (60%). Of these, 22.7% received unstructured follow-up and 40.6% received PEP care. Peritoneal dialysis (PD) was the first choice modality for 41.5% of patients and 55% had a planned start. Excluding late referrals (36.7%), the likelihood of PD selection was similar between PEP and unstructured care (52.7% vs. 40.4%, p = NS), while that of a planned start was greater among PEP patients (91.4% vs. 38.5%, p < 0.001). Multivariate analysis showed that only PEP (but not unstructured care) vs. late referral had a significant association with reduced odds of hemodialysis (HD) selection (OR: 0.301, [95%CI 0.153, 0.594]), emergency start (0.031 [0.013, 0.075]), 1st hospitalization > 5 days (0.165 [0.081, 0.333]), and further hospitalizations (0.346 [0.174, 0.685]). Late referrals independently predicted the lack of modality selection (1.847 [1.007, 3.388]).
A structured PEP seemed to improve early dialysis outcomes and resource usage beyond that gained by a timely referral, except for the opportunity to select modality.
在肾病科医生处就诊后3个月内开始慢性透析的患者（延迟转诊）发病率和死亡率增加。然而，对于早期透析结局和资源利用而言，正式的透析前教育项目（PEP）是否比非结构化的专科随访更具优势尚不清楚。
我们前瞻性收集了1999年1月1日至2002年6月30日期间在意大利两个中心开始透析的所有连续患者在透析前3个月内的专科护理、非结构化或PEP、透析方式选择和住院情况的信息。
参与本研究的229例患者（62%为男性，中位年龄70岁）糖尿病患病率高（27.5%），心血管疾病患病率高（60%）。其中，22.7%接受非结构化随访，40.6%接受PEP护理。41.5%的患者首选腹膜透析（PD），55%的患者计划开始透析。排除延迟转诊患者（36.7%）后，PEP组和非结构化护理组选择PD的可能性相似（52.7%对40.4%，p=无显著性差异），而PEP组患者计划开始透析的可能性更大（91.4%对38.5%，p<0.001）。多因素分析显示，仅PEP（而非非结构化护理）与延迟转诊相比，与血液透析（HD）选择几率降低（比值比：0.
301，[95%置信区间0.153，0.594]）、急诊开始透析（0.031[0.013，0.075]）、首次住院>5天（0.165[0.081，0.333]）以及再次住院（0.346[0.174，0.685]）显著相关。延迟转诊独立预测缺乏透析方式选择（1.847[1.007，3.388]）。
除了选择透析方式的机会外，结构化的PEP似乎比及时转诊更能改善早期透析结局和资源利用。
