Division of Nephrology, Humber River Regional Hospital, University of Western Ontario, Toronto, Ontario, Canada.
Am J Kidney Dis. 2013 Jul;62(1):187-98. doi: 10.1053/j.ajkd.2013.02.351. Epub 2013 Apr 6.
Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.
强化（更长、更频繁）血液透析已成为治疗终末期肾病患者的替代传统血液透析的方法。然而，鉴于强化透析与常规透析在透析方式和护理模式上的差异，可能需要采用替代的患者管理方法。本研究旨在为加拿大肾脏病学会制定临床实践指南。我们采用 GRADE（推荐评估、制定与评价）方法进行指南制定，并进行了有针对性的系统评价和荟萃分析（如有必要），以解决优先考虑的临床管理问题。我们纳入了评估短时间（每周≥5 天，每次<3 小时）、长时间（每周 3-4 天，每次≥5.5 小时）或长频度（每周≥5 天，每次≥5.5 小时）血液透析治疗终末期肾病患者的研究。我们纳入了有或没有对照组的临床试验和观察性研究（1990 年及以后）。基于优先排序，有 6 项感兴趣的干预措施，包括最佳血管通路类型、扣眼穿刺、扣眼穿刺的抗菌预防、密闭连接器装置，以及接受强化血液透析患者的透析液钙和透析液磷添加剂。我们制定了 6 项关于干预措施的推荐意见。证据总体质量非常低，所有建议均为有条件的。我们提供了详细的评论，以指导共同决策。主要限制是证据的总体质量非常低，因此无法做出强有力的推荐。大多数纳入的研究是小型单臂观察性研究。有 3 项随机对照试验是适用的，但提供的是间接证据。缺乏关于患者价值观和偏好的已发表信息。总之，我们为强化血液透析的实践提供了 6 项建议。然而，由于证据质量非常低，所有建议均为有条件的。因此，我们还强调了未来研究的重点。
