Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect.
Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect.
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肾科医生插入腹膜透析导管的重要性：熟能生巧。
DOI：
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发表时间：
2009
影响因子：
--
通讯作者：
K. Chow
中科院分区：
文献类型：
--
作者：
P. Li;K. Chow
“熟能生巧”是我们在成长和教育过程中最常听到的格言之一。事实上，我们相信这条规则在应用于腹膜透析实践时非常有意义。到目前为止，还没有足够的可靠的随机试验来搅动大锅，确定一种透析方式优于另一种透析方式（如果有的话）。尽管每个人都同意腹膜透析与血液透析的选择是一种个性化的选择，但患者选择的最佳方法仍存在激烈争论[1]。关键的问题是患者是否表现出更好的生存与一个特定的透析模式比另一个。越来越多的证据表明，中心效应在决定治疗成功方面发挥着重要作用。例如，基于人群或全国性队列的数据显示，腹膜透析治疗患者的累积数量增加与腹膜透析期间患者生存率的改善相关[2]。在加拿大，技术失败率和协变量校正的死亡率随着接受治疗的腹膜透析患者数量的增加而显著下降（每个中心）[3]。例如，由累积腹膜透析患者计数>500的中心治疗的患者的死亡风险降低了29%。当根据腹膜透析的实用性对中心进行进一步分类时，发现开始腹膜透析的患者百分比较高的中心的技术失败率显着较低[3]。在荷兰透析登记研究分析[4]、美国肾脏数据系统和美国最近的队列中发现了类似的结果[5-7]。将这些登记数据放在背景下，来自腹膜透析经验和专业化程度更高的中心的肾病学家可能对感染并发症、腹膜通路创建、容量状态和心血管疾病提供更有效的管理。那么肾脏科医生插入腹膜导管的意义是什么呢？肾科医生插入腹膜透析导管的实践对治疗结果有很大贡献，部分原因是它增强了腹膜透析渗透，以及中心大小对技术成功率和患者生存结局的一致有益影响。为什么肾科医生插入腹膜透析导管很重要？这个问题不仅仅是病人护理连续性的需要。在所有的可能性中，最终目标是提供及时有效的导管插入，而没有过长的等待时间或延迟，在此期间，腹膜透析的潜在候选人可能会对这种透析方式失去兴趣。在一个手术室时间表紧张已成为规则而不是例外的时代，转诊到外科医生（并安排手术室）进行导管插入成为开始腹膜透析的限速步骤。此外，在大多数透析中心，缺乏对腹膜导管放置有浓厚兴趣的专业手术团队。冗长的等待插入导管的名单使肾内科医生和患者都感到沮丧，导致对腹膜透析信心的最终侵蚀。在这种情况下，肾科医生插入导管是成功的腹膜透析计划的关键组成部分。有大量证据表明，肾脏科医生插入导管可提高腹膜透析利用率，并增加腹膜透析人群的增长率[8- 11]。重要的是，肾科医生的导管插入是由每个中心腹膜透析患者数量的变化所决定的。例如，在美国的三个中心，肾科医生开始插入导管与腹膜透析患者数量增加22-32%相关[8]，而外科医生重新插入导管导致腹膜透析人群下降[8]。在其他研究中，在开发综合基础设施和支持系统（包括肾病学家插入导管）后，观察到腹膜透析渗透率的类似增长[9-11]。特别是，在一个马来西亚透析单位中，肾科医生插入导管的普遍政策与腹膜透析的渗透率相比血液透析显著增加有关，这是全国平均水平的四倍[11]。总之，这些研究表明，肾科医生插入腹膜透析导管减少了等待时间，因此提高了腹膜透析吸收;后者
‘Practice makes perfect’ is one of the most oft-heard aphorisms during our years of upbringing and education. Indeed, we believe that this rule makes perfect sense when applied to the practice of peritoneal dialysis. To date, there have been no robust randomized trials qualified enough to stir the cauldron that determines superiority (if any) of one dialysis modality over another. Although everyone agrees that selection of peritoneal dialysis versus haemodialysis is an individualized choice, the optimal means of patient selection is hotly debated [1]. The key question is whether patients have shown better survival with one particular modality of dialysis versus another. Accumulating evidence shows an important role for the centre effect in determining treatment success. For example, data from population-based or nationwide cohorts show that increasing cumulative numbers of treated peritoneal dialysis patients are associated with improved patient survival during peritoneal dialysis [2]. In Canada, technique failure rates and covariate-adjusted mortality decreased significantly with increasing numbers of peritoneal dialysis patients being treated (by each individual centre) [3]. For example, patients treated by centres with >500 cumulative peritoneal dialysis patient counts had a 29% reduction in mortality risk. When the centres were further classified by the utility of peritoneal dialysis, significantly lower technique failure rates were found in centres having a higher percentage of patients initiating dialysis on peritoneal dialysis [3]. Similar results were found in the Dutch dialysis registry analysis [4], the United States Renal Data System and in more recent cohorts from the United States [5–7]. To put these registry data in context, it is possible that nephrologists from centres with more experience and specialization with peritoneal dialysis provided more effective management of infectious complications, peritoneal access creation, volume status and cardiovascular disease. What then are the implications for peritoneal catheter insertion by nephrologists? The practice of peritoneal dialysis catheter insertion by nephrologists substantially contributes to treatment outcomes, in part, because it enhances peritoneal dialysis penetration and because of the consistent salutary effect of centre size on technique success rates and patient survival outcomes. Why does insertion of peritoneal dialysis catheters by nephrologists matter? This issue is more than just the mere need for continuity in patient care. In all likelihood, the ultimate goal is to provide timely and effective catheter insertion without unduly long waiting times or delay, during which potential candidates for peritoneal dialysis may lose interest in this dialysis modality. In an age where tight operating theatre schedules have become the rule rather than the exception, referral to a surgeon (and scheduling an operating theatre) for catheter insertion becomes the rate-limiting step for initiating peritoneal dialysis. In addition, there is a dearth of committed surgical teams having a keen interest in peritoneal catheter placement in most dialysis centres. A lengthy waiting list for catheter insertion is demoralizing for both renal physicians and patients alike, causing an ultimate erosion of confidence in peritoneal dialysis. In this context, catheter insertion by nephrologists is a critical component of a successful peritoneal dialysis programme. There is a plethora of evidence to suggest that catheter insertion by nephrologists improves peritoneal dialysis utilization and increases the peritoneal dialysis population growth rate [8– 11]. Importantly, catheter insertion by nephrologists was paralleled by a change in the number of peritoneal dialysis patients in each centre. For instance, initiation of catheter insertion by nephrologists in three centres in the United States was associated with a 22–32% increase in the number of peritoneal dialysis patients [8], whereas a return to catheter insertion by surgeons led to a decline in the peritoneal dialysis population [8]. In other studies, a similar growth in the peritoneal dialysis penetration was seen following the development of comprehensive infrastructure and support systems that included catheter insertion by nephrologists [9–11]. In particular, a universal policy of catheter insertion by nephrologists in one Malaysian dialysis unit was associated with a dramatically increased penetration ratio of peritoneal dialysis compared to haemodialysis, representing a quadrupling from that of the national average [11]. Together, these studies show that peritoneal dialysis catheter insertion by nephrologists reduces the waiting times and therefore enhances peritoneal dialysis uptake; the latter
CAPD 连接技术的腹膜炎风险和技术失败：一项国家研究。
影响因子：
19.6
作者：
Port,FK;Held,PJ;Nolph,KD;Turenne,MN;Wolfe,RA
通讯作者：
Wolfe,RA