早期转诊政策背景下的透析选择：自我护理存在空间。
Dialysis choice in the context of an early referral policy: there is room for self care.
作者信息
Piccoli Giorgina B, Mezza Elisabetta, Burdese Manuel, Consiglio Valentina, Vaggione Silvia, Mastella Claudia, Jeantet Alberto, Maddalena Emanuela, Martina Guido, Gai Massimo, Motta Daria, Segoloni Giuseppe Paolo, Piccoli Giuseppe
机构信息
Department of Internal Medicine, University of Torino, Torino, Italy.
出版信息
J Nephrol. 2005 May-Jun;18(3):267-75.
BACKGROUND
Predialysis care is vital for the patient and is crucial for dialysis choice: empowered, early referred patients tend to prefer out-of-hospital and self-care treatment; despite these claims, early referral remains too often a program more than a reality. Aim of the study was to evaluate the pattern and reasons for RRT choice in patients treated in a long-standing outpatient network, presently following 850 chronic patients (about 80% diabetics), working with an early referral policy and offering a wide set of dialysis options (home hemo and PD; self care and limited care hemodialysis; hospital hemodialysis).
METHODS
Prospective historical study. All patients who started RRT in January 2001-December 2003 were considered. Correlations between demographical (sex, age, educational level) or clinical variables (pre-RRT follow-up, comorbidity, SGA and Karnofsky) and treatment choice have been tested by univariate (chi-square, Kruskal-Wallis) and multivariate models (logistic regression), both considering all choices and dichotomising choice into "hospital" versus "out of hospital dialysis".
RESULTS
Hospital dialysis was chosen by 32.6% of patients; out of hospital in 67.4% (PD 26.5%, limited-care 18.4%, home hemodialysis 4.1%, self-care 18.4%). Hospital dialysis and PD were chosen by elderly patients (median age: 67.5 and 70 years respectively) with multiple comorbidities (75% and 92.3%); no difference for age, comorbidity, Karnofsky, SGA and educational level. 6/13 PD patients needed the help of a partner. Self-care/home hemodialysis patients were younger (median age 52), had higher educational level (p = 0.014) and lower prevalence of comorbidity (63.6% vs 94.7% in the other dialysis patients, p = 0.006). In the context of a long follow-up period (3.9 years) a statistically significant difference was found comparing hospital dialysis (3.3 years) vs out of hospital dialysis (4.9 years) (p = 0.035). In a logistic regression model, only pre-RRT follow-up was correlated with dialysis "hospital vs "out of hospital" choice (p = 0.014).
CONCLUSION
Early nephrological follow-up may enhance self and home-based dialysis care.
背景
透析前护理对患者至关重要，且对透析方式的选择至关重要：获得充分信息且转诊较早的患者往往倾向于选择院外及自我护理治疗；尽管有这些说法，但早期转诊往往更多是一个计划而非现实。本研究的目的是评估在一个长期的门诊网络中接受治疗的患者选择肾脏替代治疗（RRT）的模式及原因，该网络目前有850名慢性病患者（约80%为糖尿病患者），实行早期转诊政策并提供多种透析选择（家庭血液透析和腹膜透析；自我护理和有限护理血液透析；医院血液透析）。
方法
前瞻性历史研究。纳入所有在2001年1月至2003年12月开始接受RRT的患者。通过单因素（卡方检验、Kruskal-Wallis检验）和多因素模型（逻辑回归）检验人口统计学（性别、年龄、教育程度）或临床变量（RRT前随访、合并症、主观全面评定法和卡氏评分）与治疗选择之间的相关性，分析时既考虑所有选择，也将选择分为“医院透析”与“院外透析”进行二分法分析。
结果
32.6%的患者选择医院透析；67.4%选择院外透析（腹膜透析占26.5%，有限护理占18.4%，家庭血液透析占4.1%，自我护理占18.4%）。医院透析和腹膜透析的选择者为患有多种合并症的老年患者（中位年龄分别为67.5岁和70岁）（分别为75%和92.3%）；在年龄、合并症、卡氏评分、主观全面评定法和教育程度方面无差异。13名腹膜透析患者中有6名需要伴侣协助。自我护理/家庭血液透析患者较年轻（中位年龄52岁），教育程度较高（p = 0.014），合并症患病率较低（其他透析患者为94.7%，自我护理/家庭血液透析患者为63.6%，p = 0.006）。在较长的随访期（3.9年）内，发现医院透析（3.3年）与院外透析（4.9年）相比存在统计学显著差异（p = 0.035）。在逻辑回归模型中，只有RRT前随访与透析“医院”与“院外”选择相关（p = 0.014）。
结论
早期肾病学随访可能会加强自我及家庭透析护理。
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