Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, 64239, Israel.
BMC Nephrol. 2012 Sep 19;13:112. doi: 10.1186/1471-2369-13-112.
Medical, ethical and financial dilemmas may arise in treating undocumented-uninsured patients with end-stage renal disease (ESRD). Hereby we describe the 10-year experience of treating undocumented-uninsured ESRD patients in a large public dialysis-unit.
We evaluated the medical files of all the chronic dialysis patients treated at the Tel-Aviv Medical Center between the years 2000-2010. Data for all immigrant patients without documentation and medical insurance were obtained. Clinical data were compared with an age-matched cohort of 77 insured dialysis patients.
Fifteen undocumented-uninsured patients were treated with chronic scheduled dialysis therapy for a mean length of 2.3 years and a total of 4953 hemodialysis sessions, despite lack of reimbursement. All undocumented-uninsured patients presented initially with symptoms attributed to uremia and with stage 5 chronic kidney disease (CKD). In comparison, in the age-matched cohort, only 6 patients (8%) were initially evaluated by a nephrologist at stage 5 CKD. Levels of hemoglobin (8.5 ± 1.7 versus 10.8 ± 1.6 g/dL; p < 0.0001) and albumin (33.8 ± 4.8 versus 37.7 ± 3.9 g/L; p < 0.001) were lower in the undocumented-uninsured dialysis patients compared with the age-matched insured patients at initiation of hemodialysis therapy. These significant changes were persistent throughout the treatment period. Hemodialysis was performed in all the undocumented-uninsured patients via tunneled cuffed catheters (TCC) without higher rates of TCC-associated infections. The rate of skipped hemodialysis sessions was similar in the undocumented-uninsured and age-matched insured cohorts.
Undocumented-uninsured dialysis patients presented initially in the advanced stages of CKD with lower levels of hemoglobin and worse nutritional status in comparison with age-matched insured patients. The type of vascular access for hemodialysis was less than optimal with regards to current guidelines. There is a need for the national and international nephrology communities to establish a policy concerning the treatment of undocumented-uninsured patients with CKD.
在治疗终末期肾病（ESRD）的无证件无保险患者时，可能会出现医学、伦理和财务方面的困境。在此，我们描述了在一家大型公立透析中心治疗大量无证件无保险 ESRD 患者的 10 年经验。
我们评估了 2000 年至 2010 年期间在特拉维夫医疗中心接受慢性透析治疗的所有慢性透析患者的病历。获取了所有无证件和无医疗保险的移民患者的数据。将临床数据与 77 名有保险的透析患者的年龄匹配队列进行比较。
15 名无证件无保险的患者接受了慢性定期透析治疗，平均治疗时间为 2.3 年，共进行了 4953 次血液透析，尽管没有报销。所有无证件无保险的患者最初都出现了尿毒症症状，并患有 5 期慢性肾脏病（CKD）。相比之下，在年龄匹配的队列中，只有 6 名患者（8%）在 5 期 CKD 时最初由肾病学家评估。血红蛋白水平（8.5±1.7 与 10.8±1.6 g/dL；p<0.0001）和白蛋白水平（33.8±4.8 与 37.7±3.9 g/L；p<0.001）在开始血液透析治疗时低于年龄匹配的有保险患者。这些显著的变化在整个治疗期间都持续存在。所有无证件无保险的透析患者均通过隧道带袖套导管（TCC）进行血液透析，而 TCC 相关感染的发生率没有更高。无证件无保险和年龄匹配的有保险患者组的血液透析漏诊率相似。
与年龄匹配的有保险患者相比，无证件无保险的透析患者在 CKD 的晚期出现，血红蛋白水平较低，营养状况更差。血液透析的血管通路类型不符合当前指南的要求。国家和国际肾脏病学会需要制定一项关于治疗 CKD 无证件无保险患者的政策。
