Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain; Department of Nephrology, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RD16/0009/0013 (ISCIII FEDER REDinREN), Barcelona, Spain.
Department of Nephrology, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RD16/0009/0013 (ISCIII FEDER REDinREN), Barcelona, Spain.
Nefrologia (Engl Ed). 2024 Jul-Aug;44(4):560-567. doi: 10.1016/j.nefroe.2024.07.002. Epub 2024 Jul 14.
The influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the "non-medical" barriers that influence the choice of RRT in an advanced chronic kidney disease (ACKD) consultation in Spain.
Retrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel Scale) and instrumental activities of daily living (Lawton and Brody Scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged.
A total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation (LDRT) and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7% vs. 22.5%) (p = 0.002), Spanish nationality (91% vs. 77.7%) (p < 0.001), to a lower language barrier (0.6% vs 10.5%) (p < 0.001), and to a higher score on the Barthel scale (97.4 vs 92.9) and on the Lawton and Brody scale (7 vs 6.1) (p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6% vs 35.2%; p = 0.006) and a higher proportion of Spaniards (94.7% vs 81%, p = 0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC.
Despite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment.
社会经济和文化障碍对终末期慢性肾脏病（ACKD）患者选择肾脏替代治疗（RRT）技术的影响鲜有研究，这可能会导致医疗保健中经常被忽视的不公平问题。本研究旨在确定影响西班牙 ACKD 咨询中 RRT 选择的“非医学”障碍。
这是一项回顾性分析，纳入了 2009 年至 2020 年在一家三级医院 ACKD 咨询中就诊的所有患者。纳入 ACKD 咨询的标准为经过专门培训的护士进行的资格测试和决策过程。研究考虑的变量包括：年龄、性别、CKD 病因、日常生活活动基本自理（巴氏量表）和工具性日常生活活动（洛顿和布罗迪量表）的依赖程度、西班牙裔与外国国籍、社会经济水平和语言障碍。社会经济水平根据患者所属的初级保健中心的家庭和健康区域进行推断。
在研究期间，共有 673 人在 ACKD 咨询中就诊，其中 400 人（59.4%）选择血液透析（HD），156 人（23.1%）选择腹膜透析（PD），4 人（0.5%）选择早期活体供肾移植（LDRT），113 人（16.7%）选择保守治疗（CC）。与 HD 相比，PD 作为 RRT 选择的比例更高（38.7%比 22.5%）（p=0.002），选择 PD 的患者社会经济水平更高（38.7%比 22.5%）（p=0.002），西班牙裔比例更高（91%比 77.7%）（p<0.001），语言障碍程度更低（0.6%比 10.5%）（p<0.001），巴氏量表评分（97.4 比 92.9）和洛顿和布罗迪量表评分（7 比 6.1）更高（p<0.001）。年龄和性别在两种技术的选择上均无显著差异。选择 CC 的患者年龄明显更大（81.1 岁比 67.7 岁；p<0.001），依赖性更强（p<0.001），女性比例更高（49.6%比 35.2%；p=0.006），西班牙裔比例更高（94.7%比 81%；p=0.001），与选择其他技术（PD 和 HD）相比。社会经济水平并不影响 CC 的选择。
尽管有规范的决策过程，但仍存在一些因素，如社会经济地位、移民、语言障碍和人群的依赖性，这些因素会影响所选择的 RRT 类型。为了解决这些可能导致不公平的问题，需要进行跨部门和多层次的干预，包括社会工作人员在内的多学科团队，提供更全面和以患者为中心的评估。
