The Role of Patient Capacity in Chronic Kidney Disease Trajectories

项目摘要/摘要 有几种形式的肾脏替代疗法(RRT)可以帮助ESKD患者，但它们并不相同 理想的，家庭透析和肾移植通常比中心血液透析更可取。 现有的最佳证据表明，与中心内透析相比，预防性肾移植 而家庭透析方式与更好的生活质量、相同或更好的存活率有关，而且 性价比高。注意到这些好处，美国卫生与公众服务部启动了 2019年推进美国肾脏健康倡议。该计划提出了80%的ESKD的目标 到2025年，接受家庭透析或接受先发制人移植的患者。然而，根据美国肾脏的数据 在2018年被诊断为ESKD的患者中，只有14%使用了家庭透析方式或接受了 先发制人的移植，尽管大多数患者在医学和心理上都符合条件 对于这些选项。 在一定程度上，这可能是由于RRT要求患者将新的医疗保健“工作量”实施到 他们的生活。在家庭透析的情况下，患者必须在没有医疗保健帮助的情况下承担这些新的任务 传统上在中心透析设施找到的专业人员。在移植的情况下，患者通常是 感到惊讶的是，由于免疫抑制、财务和医疗保健等方面的挑战，仍未恢复正常生活。 移植后的关系。当治疗工作量超过患者承受能力时，定义为患者的 获得和使用医疗服务以及在家中实施自我护理的能力和资源，患者处于危险之中 对于更糟糕的结果。这些结果在一定程度上是由不可持续的治疗负担推动的，定义为 客观治疗工作对患者的主观负面社会和情感后果。 治疗负担与患者不坚持治疗有关，已发现高达40%的患者会受到影响 患有慢性病的患者。有相当多的证据表明，病人能力是一个可修改的结构 并与CKD护理相关。它是通过患者与他们的传记(自我意识和生活)的互动而产生的 角色)、资源、环境、患者工作经验和社会网络。 在拟议的研究中，我们将确定患者容量，在进展为肾衰竭的CKD患者中， 与RRT的选择相关(目标1)。我们还将在接受RRT的ESKD患者中确定 较高的容量预示着切换到更理想的RRT形式，而较低的容量预示着切换到 不太可取的RRT形式或退出RRT(目标2)。最后，这项研究将确定 CKD/ESKD患者医学上有资格接受移植如果患者能力是移植转诊的预后， 移植批准，或在移植等待名单上的死亡(目标3)。

PROJECT SUMMARY/ABSTRACT Several forms of renal replacement therapy (RRT) exist to help patients with ESKD, but they are not equally desirable, with in-home dialysis and kidney transplantation being generally preferable to in-center hemodialysis. The best evidence available indicates that, compared to in-center dialysis, pre-emptive kidney transplantation and at-home dialysis modalities are associated with better quality of life, same or better survival, and are more cost-effective. Noting these benefits, the U.S. Department of Health and Human Services launched the Advancing American Kidney Health initiative in 2019. This program proposed a target of having 80% of ESKD patients on home dialysis or receiving a preemptive transplant by 2025. Yet, according to the U.S. Renal Data System, only 14% of patients diagnosed with ESKD in 2018 utilized a home dialysis modality or received preemptive transplant, despite the fact that the majority of patients are both medically and psychosocially eligible for these options. In part, this may be due to the work that RRT requires of patients to implement new healthcare “workload” into their lives. In the case of home dialysis, patients must shoulder these new tasks without the help of healthcare professionals traditionally found at in-center dialysis facilities. In the case of transplant, patients are often surprised by the lack of a return to “normal life” due challenges with immunosuppression, finances, and relationships that follow transplant. When treatment workload exceeds patient capacity, defined as patients’ abilities and resources to access and use healthcare services and enact self-care at home, patients are at risk for poorer outcomes. These outcomes are in part driven by unsustainable treatment burden, defined as the objective treatment work asked of patients and the subjective negative social and emotional consequences. Treatment burden is correlated with patient non-adherence and has been found to affect as many as 40% of all patients with chronic conditions. There is considerable evidence that patient capacity is a modifiable construct and relevant to CKD care. It is created through patient interaction with their biography (sense of self and life roles), resources, environment, experience of patient work, and social network. In the proposed study we will determine if patient capacity, among CKD patients who progress to kidney failure, correlates with the choice of RRT (Aim 1). We will also determine amongst ESKD patients on RRT whether higher capacity predicts the switch to a more desirable form of RRT and lower capacity predicts the switch to a less desirable form of RRT or withdrawing from RRT (Aim 2). Finally, this study will determine amongst CKD/ESKD patients medically eligible for transplant if patient capacity is prognostic for transplant referral, transplant approval, or death on the transplant wait list (Aim 3).