改善全球肾脏病预后组织慢性肾脏病矿物质和骨异常指南上海市调查问卷分析

Analysis of the questionnaire on Kidney Disease: Improving Global Outcomes chronic kidney disease-mineral and bone disorder in Shanghai

目的调查上海市54所医院肾脏内科医师对改善全球肾脏病预后组织(KDIGO)和肾脏疾病患者生存质量(KDOQI)慢性肾脏病矿物质和骨异常(CKD-MBD)指南的认同程度和目前临床实践情况。方法采取CKD-MBD调查问卷形式,分别给上海市具有独立肾脏内科的54所综合性医院发放CKD-MBD调查问卷科室版54份和医师版261份。结果 CKD-MBD科室版调查问卷的回收率为100.0%,医师版调查问卷的回收率为84.7%。22.2%的医院根据KDOQI指南治疗透析患者的CKD-MBD,20.4%的医院根据KDIGO指南,57.4%的医院同时结合两种指南。55.6%的医院认为指南执行顺利,三级医院指南执行顺利的比例显著高于二级医院(P<0.05)。几乎所有医院均开展血液生化检查,42.6%的医院开展25羟维生素D3[25(OH)D3]的检测,53.7%开展冠状动脉CT和腹部X线摄片检查,仅有18.5%的医院开展骨特异性碱性磷酸酶(bALP)的检测。行维持性血液透析患者中,正常血磷(0.80～1.78mmol/L)患者占39.6%,血钙2.10～2.54mmol/L占53.5%,全段甲状旁腺激素150～300pg/mL者占34.1%,三级医院生化指标正常的患者比例高于二级医院。行透析治疗的高磷血症患者中,92.6%的医院选择碳酸钙;38.9%的医院选择应用外科手术治疗严重的甲状旁腺机能亢进。结论目前上海市各医院肾脏内科医师主要根据KDOQI和KDIGO指南指导临床实践。CKD-MBD各指标的检测在三级医院中开展较好,bALP、25(OH)D3的检测和血管钙化检测仍存不足。行维持性血液透析患者高磷血症的发生率高,对其治疗尚缺乏有效的磷结合剂。

Objective To survey the clinic practices of Kidney Disease Outcomes Quality Initiative （KDOQI） and Kidney Disease.. Improving Global Outcomes （KDIGO} guidelines on chronic kidney disease-mineral and bone disorder （CKD-MBD） in 54 hospitals in Shanghai. Methods CKD-MBD questionnaires were sent to 54 hospitals in Shanghai, including 54 department questionnaires and 261 physician questionnaires. Results Our survey achieved a 100.0 % response rate for department questionnaires and 84.7% for physician questionnaires. In all the 54 hospitals, the treatment of CKD-MBD was based on KDOQI guideline in 22.2% hospitals, on KDIGO guideline in 20.4 % hospitals and on both guidelines in 57.4 % hospitals. Guidelines were successfully performed in 55.6% hospitals. There was a higher proportion of successful implementation for guidelines in grade-three hospitals as compared with grade-two hospitals （P 〈 0. 05）. Blood biochemical examinations were well developed. 42.6% hospitals developed 25（OH） D test, 53.7% hospitals made coronary CT angiography and lateral lumbar X-ray, while only 18. 5% hospitals developed bone-specific alkaline phosphatase （ALP） test. Serum phosphate maintained in 0.80-1.78 mmol/L in 39.6% maintenance hemodialysis （MHD） patients, serum calcium was in 2. 10- 2.54 mmol/L in 53.5% MHD patients, and parathyroid hormone （PTH） ranged 150- 300 pg/mL in 34.1% MHD patients. Calcium carbonate was used in 92.6% hospitals for MHD patients with hyperphosphatemia. Severe secondary hyperparathyroidism in MHD patients were treated by surgery in 38.9% hospitals. Conclusion Nephrelogists in Shanghai take KDOQI and KDIGO as main clinical practice guidelines. Blood biochemical examinations are well developed in grade-three hospitals. But it is important to improve the monitoring of bone-specific ALP, 25 （OH） D3 and the detection of vascular calcification. There is a high prevalence of hyperphosphatemia in MHD patients, and effective phosphate-binder for the treatment is needed.