关键词: 腹膜透析；患儿；全程照护

Abstract: Objective: To evaluate the effect of integrated care model for children undergoing peritoneal dialysis with End Stage Renal Disease. Methods: A multidisciplinary, integrated care model was applied among children undergoing peritoneal dialysis aged 0 to 18 years old in Children' s Hospital of Fudan University from January 2012 to December 2020. The model included prescribing treatment modalities based on an expectation of dialysis and quality of life of children and their families; optimizing the treatment based on families' preference; dynamically assessing families' financial conditions and caregivers' psychological status; coordinating the resources, and assisting in applying for fundings. During the dialysis initiation, the model included comprehensive management of children and their families during hospitalization, including symptoms management, dialysis care, training and performance assessment peritoneal dialysis, and the continuous care and routine follow-ups of families with children undergoing peritoneal dialysis after discharge. Results: From 2018 to 2020, the peritonitis rate was 0.10-0.12 per patient-year. The optimized outcomes of peritoneal dialysis were achieved through continuous quality improvement with the one-year survival rate of 97% and the 5-year survival rate of 95%. Conclusion: The implementation of the integrated care model lowered the incidence of peritoneal dialysis related complications, optimized the peritoneal dialysis treatment, and improved children's quality of life.

Key words: peritoneal dialysis; pediatric patient; integrated care