Smith Carolyn, Da Silva-Gane Maria, Chandna Shahid, Warwicker Paul, Greenwood Roger, Farrington Ken
Renal Unit, Lister Hospital, Stevenage, UK.
Nephron Clin Pract. 2003;95(2):c40-6. doi: 10.1159/000073708.
To study factors influencing the recommendation for palliative (non-dialytic) treatment in patients approaching end-stage renal failure and to study the subsequent outcome in patients choosing not to dialyse.
Cohort study of patients approaching end-stage renal failure who underwent multidisciplinary assessment and counselling about treatment options. Recruitment was over 54 months, and follow-up ranged from 3 to 57 months. Groups were defined on the basis of the therapy option recommended (palliative or renal replacement therapy).
Renal unit in a district general hospital serving a population of about 1.15 million people.
321 patients, mean age +/- SD 61.5 +/- 15.4 years (range: 16-92), 57% male, 30% diabetic.
Survival, place of death (hospital or community).
Renal replacement therapy was recommended in 258 patients and palliative therapy in 63 (19.6%). By logistic regression analysis, patients recommended for palliative therapy were more functionally impaired (modified Karnofsky scale), older and more likely to have diabetes. The comorbidity severity score was not an independent predictor. Thirty-four patients eventually died during palliative treatment, 26 of whom died of renal failure. Ten patients recommended for palliative treatment opted for and were treated by dialysis. Median survival after dialysis initiation in these patients (8.3 months) was not significantly longer than survival beyond the putative date of dialysis initiation in palliatively treated patients (6.3 months). 65% of deaths occurring in dialysed patients took place in hospital compared with 27% in palliatively treated patients (p = 0.001).
In high-risk, highly dependent patients with renal failure, the decision to dialyse or not has little impact on survival. Dialysis in such patients risks unnecessary medicalisation of death.
研究影响终末期肾衰竭患者姑息（非透析）治疗推荐的因素，并研究选择不透析患者的后续结局。
对接受多学科治疗方案评估和咨询的终末期肾衰竭患者进行队列研究。招募时间超过54个月，随访时间为3至57个月。根据推荐的治疗方案（姑息治疗或肾脏替代治疗）对患者进行分组。
一家为约115万人口服务的地区综合医院的肾脏科。
321例患者，平均年龄±标准差为61.5±15.4岁（范围：16 - 92岁），男性占57%，糖尿病患者占30%。
生存率、死亡地点（医院或社区）。
258例患者被推荐接受肾脏替代治疗，63例（19.6%）被推荐接受姑息治疗。通过逻辑回归分析，被推荐接受姑息治疗的患者功能受损更严重（改良卡诺夫斯基量表）、年龄更大且更可能患有糖尿病。合并症严重程度评分不是独立预测因素。34例患者在姑息治疗期间最终死亡，其中26例死于肾衰竭。10例被推荐接受姑息治疗的患者选择并接受了透析治疗。这些患者开始透析后的中位生存期（8.3个月）并不显著长于姑息治疗患者推测的透析开始日期后的生存期（6.3个月）。透析患者中65%的死亡发生在医院，而姑息治疗患者中这一比例为27%（p = 0.001）。
在高危、高度依赖的肾衰竭患者中，透析与否的决定对生存率影响不大。此类患者透析存在使死亡不必要地医疗化的风险。
