摘要
慢性肾脏病末期在台湾地区有极高的发病率和患病率及庞大的医疗支出,降低末期肾脏疾病发生率一直为台湾地区肾脏病防治工作的重要任务。目前慢性肾脏病诊疗指引建议肾小球滤过率<30mL/(min·1.73m2)的肾脏病患者,交由跨专业照护团队介入管理。跨专业照护团队成员除了肾脏科医师外,需包括护理师、药师、营养师及社工等,以保存肾功能及减少并发症为目标,提供营养及肾毒性药物咨询、各种肾脏替代疗法模式及教育、肾脏移植选择、透析通路手术、心理及社会支持;以上建议在预计透析开始前1年即应进行,以让患者有充分心理准备。接受慢性肾脏病整体照护计划多面向照顾,可推迟慢性肾脏病病程进展至肾脏病末期,减少慢性肾脏病死亡率与住院率,减缓肾功能下降速率,患者有较佳医疗与生活质量,且降低医疗费用支出。此外,接受整合型照护的慢性肾脏病晚期患者,进入血液透析时,有较高比率已完备动静脉血管通路,可避免进入透析时住院处置,并且有效降低住院医疗费用及整体医疗花费,更可以减少透析后3年内的死亡风险。而现阶段与未来进一步发展的慢性肾脏病跨专业照护团队工作包含:①提供个人化的肾脏病治疗模式与卫教照护,导入心脏-肾脏-糖尿-神经整合性照护模式;②新慢性肾脏病心关怀科技照护模式;③推动医病共享决策之肾脏替代疗法选择(肾脏移植、腹膜透析、血液透析);④推行预立医疗照护咨商于慢性肾脏病暨末期肾病安宁缓和疗护。所有的跨专业照护团队都希望成立以人为本的照护理念,提供更优质的照护模式,不仅针对患者的个人化医疗照护,更希望能够精进整体肾脏病照护与防治工作,并将此肾脏病照护与防治经验推广到全球各地。
The prevalence, incidence, and medical expenses of end-stage renal disease (ESRD) is extremely high in Taiwan, China;so decreasing the incidence of ESRD is a major work for kidney disease prevention in Taiwan, China.Current chronic kidney disease (CKD) guideline suggests multidisciplinary team (MDT) care for CKD patient with estimated glomerular filtration rate (eGFR) less than 30 mL/(min·1.73 m2). MDT includes not only nephrologist but also nursing specialty, dietitian, social worker, psychologist, and other professional personnel. The aim of the MDT care is to preserve renal function, decrease complications, provide nutrient support and nephrotoxic drug consultation, establish the concept of renal replacement therapy and preparation for dialysis access, provide the renal transplantation information, and give the psychosocial support. These cares should provide to CKD patients one year before starting renal replacement therapy. The MDT care for CKD could delay the progression from CKD to ESRD, lower the mortality and hospitalization of CKD, slow the renal function decline, provide better medical care and quality of life for patients, and decrease the medical expenditures. Besides, advanced CKD patients receiving MDT care have higher arteriovenous access preparation rate that prevent the additional intervention and hospitalization while starting dialysis. MDT care also decreases the hospitalization costs and medical expenditures, and decrease 3-year mortality rate after dialysis initiation. The further developing MDT care includes:(1) providing personalized renal care and treatment model, and intergraded care by cardiology-nephrology-diabetes-neurology model;(2) new iCKD care with health management platform and care mode combined with communication technology;(3) shared decision making for choice of renal replacement therapy;(4) advance care planning clinic for palliative treatment of ESRD. All MDT care hopes to establish a person-oriented care policy, provides a better quality care model, not only for the patie
作者
吴秉勋
陈鸿钧
WU Ping-Hsun;CHEN Hung-Chun(Division of Nephrology,Department of Internal Medicine,Kaohsiung Medical University Hospital,Kaohsiung,Taiwan 80708,P. R. China;College of Medicine,Kaohsiung Medical University,Kaohsiung,Taiwan 80708,P. R. China;Faculty of Renal Care,College of Medicine,Kaohsiung Medical University,Kaohsiung,Taiwan 80708,P. R. China)
出处
《华西医学》
CAS
2019年第7期727-735,共9页
West China Medical Journal
关键词
慢性肾脏病
肾功能
尿蛋白
跨专业照护团队
Chronic kidney disease
Renal function
Proteinuria
Multidisciplinary team
