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[BMJ发布指南]:NICE肾脏替代治疗指南总结
2018年12月03日 指南导读, 进展交流 暂无评论

GUIDELINES

Renal replacement therapy: summary of NICE guidance

James Gilbert, Kate Lovibond, Andrew Mooney, et al

BMJ 2018;363:k4303

doi: 10.1136/bmj.k4303

Indications for starting renal replacement therapy

• Consider starting dialysis when indicated by the impact of symptoms of uraemia on daily living, or biochemical measures, or uncontrollable fluid overload, or at an eGFR of around 5-7 mL/min/1.73 m2 if there are no symptoms. [Based on low quality evidence from a randomised controlled trial, cost effectiveness evidence and the experience and opinion of the Guideline Committee (GC)]

• Ensure the decision to start dialysis is made jointly by the person (or, where appropriate, their family members or carers) and their healthcare team. [Based on the experience and opinion of the GC]

• Before starting dialysis in response to symptoms, be aware that some symptoms may be caused by non-renal conditions. [Based on the experience and opinion of the GC]

Preparing for renal replacement therapy or conservative management

The Guideline Committee also considered those people who start renal replacement therapy in an unplanned way. Unplanned starts generally result in worse clinical outcomes (missed opportunities for pre-emptive transplantation and higher morbidity and mortality rates). People who start unplanned renal replacement therapy include those who were previously known to renal services but were inadequately prepared because of patient or service factors; those with previously undiagnosed chronic kidney disease; and those with acute kidney injury which fails to resolve. The committee recommended that assessment for renal replacement therapy or conservative management be started at least one year before dialysis or transplant is likely to be needed. The committee hope this will increase opportunities for supporting patient choice and reduce the frequency of unplanned starts.

• Start assessment for renal replacement therapy or conservative management at least one year before therapy is likely to be needed, including for those with a failing transplant. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

Choosing modalities of renal replacement therapy or conservative management

• Offer a choice of renal replacement therapy or conservative management to people who are likely to need renal replacement therapy. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• Ensure that decisions about renal replacement therapy modalities or conservative management are made jointly with the person (or with their family members or carers for children or adults lacking capacity) and healthcare team, taking into account:

 

–  Predicted quality of life

–  Predicted life expectancy

–  Person’s preferences

–  Other factors such as co-existing conditions.

[Based on qualitative evidence and the experience and opinion of the GC]

• Offer people (and their family members or carers, as appropriate) regular opportunities to:

–  Review the decision regarding renal replacement therapy

modalities or conservative management

–  Discuss any concerns or changes in their preferences.

[Based on qualitative evidence and the experience and opinion of the GC]

Transplantation

• Discuss the individual factors that affect the risks and benefits of transplantation with all people who are likely to need renal replacement therapy, and their family members or carers (as appropriate). [Based on qualitative evidence and the experience and opinion of the GC]

• Include living donor transplantation in the full informed discussion of options for renal replacement therapy. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• Offer a pre-emptive living donor transplant (when there is a suitable living donor) or pre-emptive listing for deceased donor transplantation to people considered eligible after a full assessment. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• Do not exclude people from receiving a kidney transplant based on BMI alone. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

Choice of dialysis modality

• Offer a choice of dialysis modalities at home or in centre, ensuring that the decision is informed by clinical considerations and patient preferences (see above). [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• Offer all people who choose peritoneal dialysis a choice of continuous ambulatory peritoneal dialysis or automated peritoneal dialysis if this is medically appropriate. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• Consider peritoneal dialysis as the first choice for children aged ≤2 years old. [Based on very low quality evidence from non-randomised studies and the experience and opinion of the GC]

• For people who choose haemodialysis or haemodiafiltration:

–  Consider haemodiafiltration rather than haemodialysis if

performed in a treatment centre (hospital or satellite unit)

–  Consider either haemodiafiltration or haemodialysis at home, taking into account the suitability of the space and facilities.

[Based on very low quality evidence from randomised controlled trials, cost effectiveness analysis, and the experience and opinion of the GC]

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