多学科团队管理血栓性微血管病的影响。
Impact of a multidisciplinary team for the management of thrombotic microangiopathy.
机构信息
Nephrology Department, Son Espases University Hospital, Palma de Mallorca, Spain.
Hematolgy Department, Son Espases University Hospital, Palma de Mallorca, Spain.
出版信息
PLoS One. 2018 Nov 2;13(11):e0206558. doi: 10.1371/journal.pone.0206558. eCollection 2018.
BACKGROUND
Thrombotic microangiopathy (TMA) is an important complication associated with several diseases that are rare and life-threatening. TMA is common to thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). TTP is defined by a severe deficiency of ADAMTS13, and early treatment is associated with good prognosis. The diagnosis of HUS can be difficult due to the potential multiple etiologies, and the best treatment option in most cases is not well-established yet. The implementation of a multidisciplinary team (MDT) could decrease the time to diagnosis and treatment for HUS and may improve the outcomes of these patients.
OBJECTIVE
To determine the impact of MDT on morbidity and mortality [death or chronic renal replacement therapy (CRRT) requirements], incidence and response time [(RT) defined as the period between hospital admission and the first day of direct therapy administration], length of stay at an intensive care unit (ICU-LOS) and total hospitalization (T-LOS) were also assessed.
METHODS
We compared a pre-MDT implementation period (from January/2008 to May/2016) versus post-MDT period (from May/2016 to December/2016). The screening TMA diagnosis was made according the following criteria: hemolytic anemia, thrombocytopenia and acute renal damage and without ADAMTS13 deficiency. An online chat was implemented to provide instant medical information.
RESULTS
Twenty-eight patients were included. The incidence changed from 2.3 cases/pre-MDT: (all cases: n = 18) to 10 cases/year post-MDT (all cases: n = 10). Two patients died in pre-MDT and post- MDT (11% versus 20%, P = 0.60). From pre-MDT, the number of patients who required CRRT by post-MDT decreased from 7 (39%) to 0, P = 0.03. Similarly, RT, ICU-LOS and T-LOS [median(p25-p75)] decreased from 10 (2-12) days to 0.5 (0-1.5) days, P = 0.04, from 16 (9-30) days to 10 (4-13) days, P = 0.01 and from 33 (22-53) days to 16 (12-32) days, P < 0.01, respectively.
CONCLUSION
MDT implementation was associated with a greater number of patients who meet TMA criteria. A decrease in the RT and T-LOS periods were observed and associated with better outcomes in these patients.
背景
血栓性微血管病（TMA）是与几种罕见且危及生命的疾病相关的重要并发症。TMA 常见于血栓性血小板减少性紫癜（TTP）和溶血尿毒综合征（HUS）。TTP 定义为 ADAMTS13 严重缺乏，早期治疗与良好的预后相关。由于潜在的多种病因，HUS 的诊断可能具有挑战性，并且在大多数情况下，最佳治疗选择尚未确定。多学科团队（MDT）的实施可以减少 HUS 的诊断和治疗时间，并可能改善这些患者的结局。
目的
确定 MDT 对发病率和死亡率[死亡或慢性肾脏替代治疗（CRRT）需求]、发生率和反应时间[RT，定义为从入院到开始直接治疗的第一天的时间]、重症监护病房（ICU）住院时间（ICU-LOS）和总住院时间（T-LOS）的影响。
方法
我们比较了 MDT 实施前（2008 年 1 月至 2016 年 5 月）和 MDT 实施后（2016 年 5 月至 2016 年 12 月）的情况。根据以下标准进行 TMA 筛查诊断：溶血性贫血、血小板减少和急性肾损伤，且 ADAMTS13 无缺乏。实施了在线聊天以提供即时医疗信息。
结果
共纳入 28 例患者。发病率从 MDT 实施前的 2.3 例/年（所有病例：n = 18）增加到 MDT 实施后的 10 例/年（所有病例：n = 10）。MDT 实施前有 2 例患者死亡（11%），MDT 实施后有 2 例患者死亡（20%），差异无统计学意义（P = 0.60）。MDT 实施后，需要 CRRT 的患者数量从 MDT 实施前的 7 例（39%）减少至 0 例（P = 0.03）。同样，RT、ICU-LOS 和 T-LOS[中位数（p25-p75）]从 10（2-12）天减少到 0.5（0-1.5）天（P = 0.04），从 16（9-30）天减少到 10（4-13）天（P = 0.01），从 33（22-53）天减少到 16（12-32）天（P < 0.01）。
结论
MDT 的实施与更多符合 TMA 标准的患者相关。观察到 RT 和 T-LOS 周期缩短，与这些患者的更好结局相关。
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