Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study
Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study
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DOI：
10.1093/ndt/gfs469
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发表时间：
2013-03-01
影响因子：
6.1
通讯作者：
Lin, Chun-Liang
中科院分区：
文献类型：
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作者：
Chen, Yue-Ren;Yang, Yu;Lin, Chun-Liang
先前的研究表明，多学科的透析前教育和团队护理可能会减缓慢性肾脏病（CKD）的肾功能下降。我们的研究比较了台湾CKD患者在多学科护理（MDC）和常规护理之间的临床结局。在这项2008年至2010年的3年前瞻性队列研究中，我们从5家医院招募了1056名CKD患者，年龄20 - 80岁，接受MDC或常规护理，估计肾小球滤过率（eGFR）60 mL/min，与包括性别、年龄、eGFR和共病疾病的倾向评分一一匹配。根据NKF K/DOQI临床实践指南和台湾终末期肾病（ESRD）前护理计划，MDC团队的护理不足。比较两组进展为ESRD（开始透析）的发生率和死亡率。我们还监测了血压控制、肾功能下降率、血脂、红细胞压积和矿物质骨疾病控制。参与者多为男性（64.8岁），平均年龄为65.1岁，平均随访时间为33.1个月。MDC组血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB）、磷结合剂、维生素D3、降尿酸药物和促红细胞生成素治疗的处方率较高，继发性甲状旁腺功能亢进的控制较好。MDC组中晚期CKD IV期和V期的肾功能下降也较慢（5.1 vs 7.3 mL/min，P 0.01）。常规治疗组中临时透析导管的使用率较高，MDC干预下的CKD患者更愿意选择腹膜透析方式。考克斯回归分析显示，与常规护理组相比，MDC组因感染住院的风险降低40，患者死亡率降低51，但开始透析的风险增加68，发现MDC患者根据K/DOQI指南有更有效的药物处方，晚期/晚期CKD的肾功能下降较慢。MDC干预后，CKD患者的生存率更高，更有可能开始肾脏替代治疗（RRT），而不是死亡。
Previous studies have demonstrated that multidisciplinary pre-dialysis education and team care may slow the decline in renal function for chronic kidney disease (CKD). Our study compared clinical outcomes of CKD patients between multidisciplinary care (MDC) and usual care in Taiwan.In this 3-year prospective cohort study from 2008 to 2010, we recruited 1056 CKD subjects, aged 2080 years, from five hospitals, who received either MDC or usual care, had an estimated glomerular filtration rate (eGFR) 60 mL/min, were matched one to one with the propensity score including gender, age, eGFR and co-morbidity diseases. The MDC team was under-cared based on NKF K/DOQI clinical practice guidelines and the Taiwanese pre-end-stage renal disease (ESRD) care program. The incidence of progression to ESRD (initiation of dialysis) and mortality was compared between two groups. We also monitored blood pressure control, the rate of renal function decline, lipid profile, hematocrit and mineral bone disease control.Participants were prone to be male (64.8) with a mean age of 65.1 years and 33.1 months of mean follow-up. The MDC group had higher prescription rates of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), phosphate binder, vitamin D3, uric acid lower agents and erythropoietin-stimulating therapy and better control in secondary hyperparathyroidism. The decline of renal function in advanced stage CKD IV and V was also slower in the MDC group (5.1 versus 7.3 mL/min, P 0.01). The use of temporary dialysis catheter was higher in the usual care group, and CKD patients under MDC intervention exhibited a greater willingness to choose peritoneal dialysis modality. A Cox regression revealed that the MDC group was associated with a 40 reduction in the risk of hospitalization due to infection, and a 51 reduction in patient mortality, but a 68 increase in the risk of initiation dialysis when compared with the usual care group.MDC patients were found to have more effective medication prescription according to K/DOQI guidelines and slower renal function declines in advanced/late-stage CKD. After MDC intervention, CKD patients had a better survival rate and were more likely to initiate renal replacement therapy (RRT) instead of mortality.