【摘要】目的调查多学科医疗管理模式(multidisciplinary care，MDC)对慢性肾脏病(chronic kidney disease，CKD)非透析人群管理效果。方法采取前瞻性队列研究设计，选取兰州大学第二医院肾内科规律随访的CKD 非透析患者，根据患者意愿分为管理组和对照组。管理组通过MDC 管理，对照组采用传统模式管理，收集实验室指标，以进入终末期肾脏病(end stage renal disease，ESRD)、肌酐较基线水平升高超过50%作为本次研究的终点及次要终点事件完成统计分析。结果781 例患者完成研究，其中管理组373 例(92%)，对照组共408 例(81%)。2 年后，管理组估算肾小球滤过率(estimated glomerular filtration rate，eGFR)下降更缓慢(t= -2.606, P=0.009)。血压(＜130/80mmHg，c2=24.408，P＜0.001)、血钙(c2=4.630，P=0.031)达标率更高，血红蛋白≥110g/L 比例更高(c2=3.576，P=0.048)。管理组ESRD 的发生率降低(HR=0.448,95%CI 0.306～0.656,P＜0.001)，进行亚组分析，男性、非糖尿病CKD 人群、CKD1～3a 期人群ESRD 发生风险更低(HR 值分别为0.314，0.649，0.015；95%CI 分别为0.188～0.524，0.414～1.015，0.001～0.431；P 值分别为0.018，0.024，0.031)。结论MDC 可有效延缓CKD 进展、提高临床指标达标率。
【Abstract】Objective To investigate the effect of multidisciplinary care (MDC) on renal outcome in CKD patients. Methods This is a prospective cohort study in a single center. Patients with CKD stage 1～5 without renal replacement treatments were followed up regularly in department of nephrology of the Second Hospital of Lanzhou University. Patients were divided into receiving MDC support (intervention group, IG) and physician care alone(control group,CG) according to their wishes. Clinical and laboratory data were collected． The primary renal endpoint is the diagnosis of ESRD and the secondary renal endpoint is 50% increase in serum creatinine. Results A total of 781 patients were enrolled in the final analysis, with 373 patients(92%) of IG and 408 patients (81%) of CG. After the enrollment of 2 years, eGFR decreasing were significantly slower in IG than that in CG(t2=- 2.606，P=0.009). Patients in the IG has a higher proportion of blood pressure≤130/80mmHg (c2=24.408, P＜0.001), a higher rate of serum Ca within 2.1～-2.5mmol/L (c2=4.630, P=0.031) and a higher rate of Hb level≥110g/L (c2=3.576, P=0.048). The MDC reduced the incidence of ESRD (HR,0.448; 95% CI, 0.306-0.656; P＜0.001). Subgroup analysis shown that men gender [HR,0.314 (0.188～0.524), P=0.018], without diabetes [HR, 0.649 (0.414～1.015), P=0.024] and CKD 1～3a group [HR, 0.015 (0.001～0.431), P= 0.031] had lower incident of ESRD. Conclusions MDC management can effectively delay the progress of CKD and improve the compliance rate of indicators.
[1] Levey AS, de Jong PE, Coresh J, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report. Kidney Int, 2011, 80(1):17-28.
[2] Zhang L, Wang F, Wang L, et al.Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet, 2012, 379(9818):815-822.
[3] 张文君, 王文革, 梁耀军, et al.甘肃省终末期肾病患者的临床特征和现状. 中华肾脏病杂志, 2015, 31(8):567-571.
[4] Bayliss EA, Bhardwaja B, Ross C, et al. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol, 2011, 6(4):704-710.
[5] Curtis BM, Ravani P, Malberti F, et al.The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant, 2005, 20(1):147-154.
[6] Sarnak MJ, Greene T, Wang X, et al.The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study. Ann Intern Med, 2005, 142(5):342-351.
[7] Appel LJ, Wright JT, Jr., Greene T, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med, 2010, 363(10):918-929.
[8] Bakris GL, Sarafidis PA, Weir MR, et al.Renal outcomes with different fixed-dose combination therapies in patients with hypertension at high risk for cardiovascular events (ACCOMPLISH): a prespecified secondary analysis of a randomised controlled trial. Lancet, 2010, 375(9721):1173-1181.
[9] Jacobs C, Frei D, Perkins AC.Results of the European Survey on Anaemia Management 2003 (ESAM 2003): current status of anaemia management in dialysis patients, factors affecting epoetin dosage and changes in anaemia management over the last 5 years. Nephrol Dial Transplant,2005, 20 Suppl 3:iii3-24.
[10] Kidney disease: improving global outcomes (KDIGO) CKD-MBD update work group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD) . Kidney Int Suppl, 2017, 7: 1-59.
[11] Menon V, Wang X, Sarnak MJ, et al.Long-term outcomes in nondiabetic chronic kidney disease. Kidney Int, 2008, 73(11):1310-1315.
