Brookwood Baptist Health Medical Education, Birmingham, AL, USA.
J Gen Intern Med. 2019 Oct;34(10):2246-2253. doi: 10.1007/s11606-019-05237-7. Epub 2019 Aug 6.
Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.
美国所有终末期肾病（ESRD）患者都可获得肾脏替代治疗。ESRD 的无证移民是肾衰竭患者中特别脆弱的亚群。这些患者除了在“紧急医疗状况”期间必须得到治疗的要求，以及联邦立法将他们排除在上述肾脏替代治疗保证之外，没有其他联邦立法。不同的州已经制定了不同的方法来处理这个问题，即使在中心与中心之间也存在管理上的差异。对文献中发表的原始研究的回顾揭示了这种情况在医学、伦理和财务方面存在的问题。与慢性门诊护理相比，这些患者在紧急透析模式下经常出现就诊延迟、常规护理机会减少、并发症增加、服务利用增加以及发病率和死亡率增加。对于那些知道自己提供的护理标准不高的从业者来说，他们代表了一个伦理困境，偶尔还需要决定如何分配资源。紧急透析与补偿不足、持续失业的威胁增加以及医疗保健基础设施负担过重有关。这种做法使患者面临风险，给提供者带来不公平的伦理负担，在财务上也不可持续。本文还考虑了肾移植和腹膜透析的特殊考虑因素，并回顾了新模型的考虑因素。最终，必须在政府、医疗保健从业者和设施的参与下做出调整，以保护这些脆弱的患者。
