腹膜透析缘何不再受重视？

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Reasons for the Decrease in Peritoneal Dialysis Utilization in the United States

A major problem for advocates for peritoneal dialysis (PD) is the decline in prevalent and incident end-stage renal disease (ESRD) patients treated with PD as reported in the US Renal Data System (USRDS) database. Thus, the 2007 USRDS report notes that less than 8% of both incident and prevalent ESRD patients were treated with PD in 2005.[1] The reasons for this decline are not obvious and have led to informal discussions among a group of nephrologists to discuss this issue and address the reasons for this decline. This group has focused attention on a variety of arenas that they feel need to be addressed.
美国肾脏数据系统的数据库显示，腹膜透析倡导的主要障碍在于终末期肾病患者的减少。美国肾脏数据系统的报告显示，2005年，不足8%的终末期肾病患者采用腹膜透析法。降低的原因并不清楚，因此引起了肾病学家们的私下里的讨论。这个小组已经开始关注他们认为需要加以研究的各个领域。

Before discussing the groups' suggestions, it should be noted that the United States ranks well below many other countries in North America (eg, Canada and Mexico), Europe (eg, the United Kingdom and The Netherlands), and Asia (eg, Hong Kong) in terms of PD utilization.[1] Furthermore, the percent of patients on PD varies widely by state, with some states, such as Alaska, Idaho, and Connecticut, having about 20% of their ESRD patients on PD.[1] In addition, when nephrologists in the United States and New England were questioned about what percent of ESRD patients they thought should be maintained on PD, the nephrologists indicated between 30% and 35%, similar to the numbers reported by Canadian and UK nephrologists.[2,3] The major reasons for the decline in PD utilization noted by the group are summarized in the Table .
在讨论他们的结论之前，应该指出的是，美国的腹膜透析率远低于许多其他地区的国家：北美地区（例如加拿大和墨西哥），欧洲（例如英国和荷兰）和亚洲（例如香港）。此外，各个州腹膜透析率也大相径庭，在一些州，比如如阿拉斯加，爱达荷和康涅狄格州，这个数字是20%。另外，当美国和新英格兰的肾病学家被问及腹膜透析率应该在一个什么水平时，回答是30%到35%，这个数字与加拿大和英国的肾病学家提及的数字是相近的。腹膜透析率下降的主要的原因总结在了表格中。

One of the major reasons for the decline in PD involves the structure and organization of PD units. The majority of units provide care for less than 10 patients, and over one third of PD patients in the United States are cared for in units with less than 20 patients. This is important because studies have shown that technique failure rates are higher in smaller sized facilities, perhaps reflecting the lack of experience and lack of adequate staff to care for complex patients.[4] The important role of nursing and the need for an adequately trained staff to take calls and support patients at home needs to emphasized.[5] Psychosocial support of patients and their family is also essential for any home-based therapy and requires that the social worker be actively engaged in patient care.[6] Depression, for example, has been associated with peritonitis rate in PD patients and thus needs to be carefully screened for.[7]
一个重要的原因是腹膜透析机构的结构和组织的不完善，大部分的机构只为10个以下的病人提供服务，而且在美国，超过1/3的患者在只为20人以下提供服务的机构接受治疗。这是个重要的问题，研究显示，技术上的失误率在小机构更高，这可能与对复杂病例缺乏经验和没有受到足够训练有关。需要得到强调是家庭护理和经过足够训练的医务人员的重要性。心理社会和家庭的支持、社工的积极性对家庭治疗的患者都是必不可少的。比如，抑郁症已被认为与腹膜炎的发病率是有关的，这一点应该的到认真对待。

Appropriate Continuous Quality Improvement programs need to be established involving all staff members (physicians, social workers, dieticians, nurses, and physician extenders). Domains that need to be routinely reviewed include peritonitis rates, exit site infections, catheter-related problems, patient satisfaction with care, patient and their family's quality of life, and whatever other issues may present in an individual facility. PD units need the staff to adequately perform these Continuous Quality Improvement programs.
适当的持续质量改进计划需要在所有的医务人员中进行（包括：医生，社会工作者，营养师，护士和广义的医师）。需要常规回顾的项目包括：腹膜炎的发病率，切口部位感染，导管相关的问题，病人的满意度，病人及其家属的生活质量，以及其他所有在个体机构中可能遇到的问题。腹膜透析机构需要对他们的员工实施充分的持续质量改进计划。

Linking to and supporting chronic kidney disease (CKD) education programs need to be emphasized. There is high turnover of PD patients. Taking into account transplantation, death, and transfer to hemodialysis (HD), only 50% of PD patients can be expected to be on the therapy 2 years after they start. Thus, there needs to be a continued influx of patients and active training to maintain an adequate census to deliver high quality care. Data from The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) database suggest that if CKD patients are offered all options, 38% of incident patients will opt for and start PD.[8] The United States does not have a good record at providing CKD education. No funding is provided to support this education, and it must be done by physicians at the time of routine office visits. Thus, when patients who had just started dialysis in southern California were asked if they were offered PD, only 35% said yes.[9] And data presented at the 2008 Annual Dialysis Conference pointed out that when patients who were being cared for by nephrologists were asked about their knowledge of PD, the majority did not report having information about this therapy.
需要强调的是与慢性肾病关联的教育。选择腹膜透析患者有很大的流失率。考虑到患者选择移植、死亡和改用血液透析，只有50%的患者两年以后还在接受腹膜透析。因此，我们需要一个持续的病人来源以及积极的训练来保持足够的统计量（选择腹膜透析的病人），以利于提供高质量的服务。来自荷兰的一个关于透析的合作研究的数据显示，如果给慢性肾病患者所有的选择的话，他们中的38%会选择腹膜透析。在美国缺少一个提供慢性肾病的教育的良好记录，没有的基金会为这样的教育提供支持，只能由医生在常规的接诊中对病人讲述相关的信息，所以才有南加州的患者刚接受洗肾被问及他们是否在进行腹膜透析时，只有35%的患者回答是肯定的。另外，2008年的透析年会上的数据也显示，当患者被问及他们了解多少腹膜透析知识时，大部分说没听说过这种治疗方法。

Another area that needs to be addressed involves problems with the training of fellows for PD. The majority of fellows have limited exposure to PD patients during their training and are not adequately trained to manage a PD unit and care for PD patients.[10] It is important that the quality of training be re-examined and basic standards of training in PD be established. If training cannot be provided at a given institution, then fellows should be assigned to rotations at institutions with well established PD programs.
另一个需要解决的问题是进行腹膜透析的医务人员的培训。他们中的大部分在培训中只能接触有限的腹膜透析病人，也没有进行管理腹膜透析机构和照顾病人的充分训练。培训的质量应该重新被评估，也应该确定一个基本的培训标准。如果一个指定的机构不能提供标准的训练，那么医务人员应该到到有腹膜透析资历的机构接受轮转培训。

Physician reimbursement for PD has been reduced and higher reimbursement can be obtained by seeing HD patients weekly than with monthly PD visits. This schema seems unreasonable given the effort that needs to be provided to support a home-based therapy -- support for not only the patients but the dialysis staff as well. Efforts need to be directed towards addressing this imbalance.
医生为腹膜透析患者服务的报酬下降，每周一次访问患者比每月一次获得的报酬要高。这个模式在提供家庭治疗支持上看起来是不合理的，我们应该既为病人也为医务人员提供支持。这个不平衡的问题需要努力得到解决。

New PD solutions have been introduced slowly in the United States. Icodextrin was released for use in the United States several years after European facilities had benefited from the availability of this solution. Amino acid-based solutions are not available in the United States, and the potential benefits of the newer more biocompatible solutions are being explored in Europe and Asia but are still not available in the United States. Unfortunately, the expense of introducing solutions in the United States and the regulations of the US Food and Drug Administration have limited US nephrologists. Instead of being at the forefront of technological change, we are now watching new developments be explored in other parts of the world.
在美国新的腹膜透析解决方案正在慢慢得到实施。艾考糊精（腹膜透析药）使欧洲机构受益几年之后，也在美国得到了应用。氨基酸为基础的透析药物也没能在美国上市，潜在的生物相容性药物正在欧洲和亚洲开发，但仍没能在美国进行类似的开发，遗憾的是，引入新药的代价和FDA的规定限制了肾病学家的努力。我们现在只能看着其他地区的新发展，而不是站在技术革新的前头。

Last is the issue of physician bias. The question of higher mortality rates for PD patients compared with HD patients has been debated for many years. Certainly for younger patients with no comorbidities, this is not the case in the United States.[11] Data from other countries' registries indicate a lower mortality rate for PD patients for the initial 2 to 3 years of therapy, and recent data from the USRDS suggest that the mortality rate for PD patients has been declining more rapidly than the mortality rate for HD patients.[1]
最后一点原因是医生们的偏见。关于腹膜透析比血液透析死亡率高的争论已经持续了很多年，然而，在美国，对于没有并发症的年轻病人来说，这并非事实。来自其他国家的数据显示，在腹膜透析治疗的最初两到三年死亡率是相对低的，最近的USRDS数据也表明，与血液透析相比，腹膜透析的死亡率正以更快的速度下降。

In summary, it is important that the problem of PD utilization in the United States be addressed. The current low utilization does not appear to be what physicians or patients want and is different from the pattern that is observed in many other countries. Addressing the problem will require that there be a re-examination of the organization of PD units, an emphasis on patient education, a reassessment of nephrology training, review of physician reimbursement for home and in-center HD, and technological exchange to permit the exploration of newer techniques.
总之，解决腹膜透析中遇到的问题是很重要的。目前的低透析率是医生和病人都不愿看到的，这也和其他许多国家不同。解决这个问题需要的是，腹膜透析机构的再检查，腹膜透析知识的强调，肾病治疗训练的再评估，医生在家庭和透析中心提供服务报酬的回顾，以及促进技术革新上的改变。