Mehrotra Rajnish, Marsh Douglas, Vonesh Edward, Peters Vickie, Nissenson Allen
Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, California 90502, USA.
Kidney Int. 2005 Jul;68(1):378-90. doi: 10.1111/j.1523-1755.2005.00453.x.
Nephrologists report that patients' choice should play an important role in the selection of renal replacement therapy (RRT) for end-stage renal disease (ESRD). In the United States, kidney transplant rates remain low and <10% of patients utilize home dialysis therapies. This study examined the effect of pre-ESRD processes on the selection of RRT among incident ESRD patients.
Using surveys, data were collected for all patients admitted to 229 dialysis units in ESRD Network 18 between April 1, 2002 and May 31, 2002. A total of 1365 patients began chronic dialysis and 1193 facility (87%) and 428 patient (31%) surveys were returned.
Substantial proportions of patients were unaware of their kidney disease (36%) or were not seeing a nephrologist (36%) until <4 months before first dialysis. The presentation of treatment options was delayed (48% either after or < 1 month before the first dialysis). The majority of ESRD patients were not presented with chronic peritoneal dialysis, home hemodialysis, or renal transplantation as options (66%, 88%, and 74%, respectively). Using multivariate analyses, variables significantly associated with selection of chronic peritoneal dialysis as dialysis modality were the probability of chronic peritoneal dialysis being presented as a treatment option and the time spent on patient education.
An incomplete presentation of treatment options is an important reason for under-utilization of home dialysis therapies and probably delays access to transplantation. Improvements in and reimbursement for pre-ESRD education could provide an equal and timely access for all medically suitable patients to various RRTs.
肾病学家指出,患者的选择应在终末期肾病(ESRD)的肾脏替代治疗(RRT)选择中发挥重要作用。在美国,肾移植率仍然很低,不到10%的患者采用家庭透析疗法。本研究调查了ESRD前期流程对初发ESRD患者RRT选择的影响。
通过调查,收集了2002年4月1日至2002年5月31日期间ESRD网络18中229个透析单位收治的所有患者的数据。共有1365例患者开始慢性透析,回收了1193份机构(87%)和428份患者(31%)调查问卷。
相当比例的患者直到首次透析前不到4个月才意识到自己患有肾病(36%)或未就诊于肾病科医生(36%)。治疗方案的介绍被推迟(48%在首次透析之后或之前不到1个月)。大多数ESRD患者未被提供慢性腹膜透析、家庭血液透析或肾移植等选择(分别为66%、88%和74%)。通过多变量分析,与选择慢性腹膜透析作为透析方式显著相关的变量是慢性腹膜透析作为治疗选择被提及的可能性以及用于患者教育的时间。
治疗方案介绍不完整是家庭透析疗法未得到充分利用的重要原因,可能也延迟了移植的时机。改善ESRD前期教育并提供报销,可为所有符合医学条件的患者平等、及时地提供各种RRT。