Elementary clinical decision analysis in evidence-based nephrology

To assess the potential contribution of elementary decision analysis to evidence-based medicine in nephrology, the treatment of primary membranous nephropathy with nephrotic syndrome is taken as an example involving quantity and quality of life, and the treatment of uremic anemia in hemodialysis patients as an example involving economic constraints of interventions. Technical details on decision tree calculation procedures, outcome quantitative assessment, and probability assignment to branches are outlined. Indications strictly based on significance tests of individual outcomes of randomized controlled trials can either miss clinical advantages or disregard economic constraints that can be easily established by decision analysis and that may have a major impact in practice.     

应用循证医学的理念推动肾脏疾病研究发展

在我国肾脏疾病的领域，循证医学（evidence based medicine．EBM）已受到人们越来越多的关注，而这方面的研究成果也不断涌现。现在，循证医学已经成为一个非常时髦的名词，但并不是所有被冠以“循证”的研究都可以指导我们的临床和科研工作。我们应该运用循证医学实事求是的理念来推动肾脏疾病研究的发展。     

循证医学在我国肾脏病学科发展中的应用现状与展望

进入21世纪以来，我国肾脏病学界对循证医学的认识及重视程度均有了很大提高，应用循证医学的知识和手段提高我国肾脏病专业的学科水平也已取得很大的成绩。这表现在应用循证医学的观点和方法进行肾脏病临床研究方面，其中突出的代表是侯凡凡等在N Eng J Med上所发表的有关血管紧张素抑制药物在非糖尿病肾脏病呈中等程度以上肾功能损伤时的肾脏保护作用及其应用的随机对照试验（RCT），以及应用来氟米特治疗狼疮肾炎的多中心前瞻性队列研究，联合应用尿激酶与苯那普利治疗重症IgA肾病的RCT及大剂量冲击与传统剂量α-（OH）-D3治疗血透患者继发性甲状旁腺功能亢进症的多中心RCT等；在肾脏疾病诊断方面有关国人评估肾小球滤过率（eGFR）公式的建立及尿蛋白与肌酐比值（ACR）测定的研究等。这些应用循证医学的方法所进行的较大样本量的临床研究引起了国际、国内同行的广泛重视，不仅为中国也为世界肾脏病学的发展作出了贡献。另一方面，近年我国各层次医院、各年资肾脏科医生应用现有的循证医学成果指导临床实践的自觉性和能力也在不断普及和提高。通过学术交流和有关临床研究稿件，可以见到越来越多地涉及和应用循证医学的研究成果。     

Producing systematic reviews of best quality: a prerequisite for evidence-based nephrology

In recent years a number of meta-analyses have been published in the renal field. These publications will be used to develop the concept of evidence-based nephrology. The design and quality of renal systematic reviews relies on technical skills and an efficient trial search. The reasons for discrepancies between systematic reviews and controlled clinical trials are now understood better and may be partly explained by inadequate trial recovery, and publication bias. Application of evidence findings is not always an easy task on the patient's level. The example of the low-protein diet in chronic renal failure highlights these obstacles. However, producing high-level systematic reviews in the renal field may greatly help in clarifying the use of controversial treatments and designing new studies.     

Outcomes research in nephrology

The field of clinical research in nephrology should be and is being broadened beyond clinical trials by incorporating epidemiologic designs and subjective patients' assessments of their own health and the degree to which they are satisfied with services they receive. The advantages of these changes include increased relevance to the concerns of patients and increased relevance to the real world of clinical practice.     

Physician-patient communication in nephrology

Training the nephrologist-to-be to physician-patient communication (PPC) has several objectives: to guide his/her history taking in order to make a diagnosis, of course, but also to help him/her establish a long-lasting relationship, inform and motivate the patient, and prepare him/her to break bad news and to deal with end-of-life issues. PPC rests on specific strategies and on the ethical grounds of a human encounter, the success of which expresses itself in care. An effective PPC offers many benefits to the patient, but also to the clinician. Talking about renal failure and dialysis, about kidney transplantation, and about withdrawing or not starting therapy: these are a few of the communicational challenges awaiting the nephrologist in training, mostly with patients requiring long-term follow-up. PPC also requires specific skills in the field of pediatric nephrology, where one deals alternately with children, adolescents and parents. Whatever the personal abilities of the nephrologist-to-be, PPC is a competency that can be learned and improved, for the benefit of the patient, and also of the physician.     

Improving the environment for women in nephrology

Data on the representation and distribution of women in nephrology and internal medicine show why continuing efforts are required to ensure that women reach their potential in academic medicine. Some of the cumulative disadvantages that women face in their professional development are summarized, particularly those related to obtaining mentoring. Efforts on the part of the Association of American Medical Colleges and one department of medicine are described as examples of strategic interventions, and other actions are suggested, with the goal of increasing women's leadership in nephrology, as well as in academic medicine overall.     

Nephrology in the clinic and quality in nephrology

The majority of patients with chronic kidney disease are followed-up in pre-dialysis clinics for a varying length of time, often for several years. The renal-team (physicians, nurses, dieticians, social assistants) intervenes on renal disease progression and educates the patient regarding the adjustments of his or her life-style to the limitations imposed by the disease. Pre-dialysis clinics are often overburdened and it is uncertain whether renal care should be based exclusively on renal teams, a difficult and costly option, or if it could be efficaciously organized by involving other health professionals. The Journal of Nephrology will maintain strong attention on these crucial issues for the future of nephrology.