Reddy Naveen C, Korbet Stephen M, Wozniak Julie A, Floramo Sheri L, Lewis Edmund J
Rush University Medical Center, Section of Nephrology, and Circle Medical Management, 1426 W. Washington Blvd, Chicago, IL 60607, USA.
Nephrol Dial Transplant. 2007 May;22(5):1399-406. doi: 10.1093/ndt/gfl809. Epub 2007 Jan 27.
The number of elderly patients undergoing chronic haemodialysis (HD) in the nursing home (NH) setting is growing; however, little published data exists on this group of patients.
We describe our experience with 271 patients undergoing staff-assisted HD in the NH setting from 1 January 2001 to 30 June 2004. Acceptance into the programme required that the patients were mentally responsive, haemodynamically stable without sepsis and not be considered terminal or in hospice.
Mean age at entry was 70.5+/-12.1 years, 53% were female, 54% were white and 34% black. Main causes of end-stage renal disease (ESRD) were diabetes mellitus (DM, 48%) and hypertension (HTN, 25%). Comorbid conditions included HTN-90%, DM-65%, coronary artery disease-54%, congestive heart failure-59%, cerebrovascular accident-31%, and 40% could not ambulate. The average time on chronic dialysis prior to entering the nursing programme was 18+/-27 months, and the median time was 4 months (range: 0.1-191 months). The average time in the NH programme was 2.9+/-3.6 months (median: 1.6 months, range: 0.1-24 months). During the study period 42% of the patients died, 37% were discharged from the NH, 4.4% withdrew from dialysis, and 16% remained active in the programme. Patient survival from entry into the NH programme was 82% at 1 month, 64% at 3 months, 38% at 6 months and 26% at 12 months (median survival of 4.1 months). However, the patient survival from initiation of chronic dialysis was 75% at 6 months, 66% at 12 months and 38% at 60 months with a median survival of 3.4 years. When evaluating patients based on the duration of chronic dialysis prior to entering the NH programme we found that established HD patients (on HD>or=12 months prior to programme entry) had fewer myocardial infarctions (15 vs 26%, P=0.05), more amputations (19 vs 8%, P=0.01), higher creatinine (6.7 vs 4.7 mg/dl, P<0.01), haemoglobin (11.1 vs 10.5 g/dl, P<0.01) and albumin (3.2 vs 3.0 g/dl, P=0.09) compared with new HD patients (on HD<or=3 months prior to programme entry). New HD patients had a higher mortality rate (50 vs 31%, P<0.01) and poorer median survival (3 vs 5 months, P<0.01) than established HD patients.
NH dialysis provides a means for dialysing our most ill and debilitated patients in the convenience and comfort of the NH setting. The success of this programme is demonstrated by the fact that almost 40% of patients are successfully rehabilitated and discharged home. Nonetheless, healthcare providers and families must recognize that patients entering an NH HD programme are a high risk population with significant morbidity and mortality. Compared with established dialysis patients, patients entering the NH programme who are new to dialysis represent a particularly high risk group. However, it is likely that the poor survival seen in the NH programme may represent end of life care, as the overall survival from initiation of chronic dialysis in this population is consistent with that of patients entering the ESRD programme at a similar age.
在养老院环境中接受慢性血液透析（HD）的老年患者数量正在增加；然而，关于这组患者的已发表数据很少。
我们描述了2001年1月1日至2004年6月30日期间在养老院环境中接受工作人员协助的血液透析的271例患者的经验。纳入该项目要求患者精神反应良好，血流动力学稳定且无败血症，并且不被视为晚期或处于临终关怀状态。
入组时的平均年龄为70.5±12.1岁，53%为女性，54%为白人，34%为黑人。终末期肾病（ESRD）的主要原因是糖尿病（DM，48%）和高血压（HTN，25%）。合并症包括HTN - 90%，DM - 65%，冠状动脉疾病 - 54%，充血性心力衰竭 - 59%，脑血管意外 - 31%，40%无法行走。进入护理项目前慢性透析的平均时间为18±27个月，中位时间为4个月（范围：0.1 - 191个月）。在养老院项目中的平均时间为2.9±3.6个月（中位时间：1.6个月，范围：0.1 - 24个月）。在研究期间，42%的患者死亡，37%从养老院出院，4.4%退出透析，16%仍积极参与该项目。从进入养老院项目开始计算，患者1个月时的生存率为82%，3个月时为64%，6个月时为38%，12个月时为26%（中位生存期为4.1个月）。然而，从开始慢性透析起患者的生存率6个月时为75%，12个月时为66%，60个月时为38%，中位生存期为3.4年。当根据进入养老院项目前慢性透析的持续时间评估患者时，我们发现已接受血液透析的患者（项目入组前接受血液透析≥12个月）心肌梗死发生率较低（15%对26%，P = 0.05），截肢发生率较高（19%对？8%，P = 0.01），肌酐水平较高（6.7对4.7 mg/dl，P < 0.01），血红蛋白（11.1对10.5 g/dl，P < 0.01）和白蛋白水平较高（3.2对3.0 g/dl，P = 0.09），与新接受血液透析的患者（项目入组前接受血液透析≤3个月）相比。新接受血液透析的患者死亡率较高（50%对31%，P < 0.01），中位生存期较差（3对5个月，P < 0.01）。
养老院透析为在养老院便利舒适的环境中为病情最重、最虚弱的患者进行透析提供了一种方式。该项目的成功体现在近40%的患者成功康复并出院回家这一事实上。尽管如此，医疗服务提供者和家属必须认识到，进入养老院血液透析项目的患者是高风险人群，具有较高的发病率和死亡率。与已接受透析的患者相比，新进入养老院项目的透析患者是一个特别高风险的群体。然而，养老院项目中观察到的较差生存率可能代表临终关怀，因为该人群从开始慢性透析起的总体生存率与类似年龄进入终末期肾病项目的患者一致。 （注：原文中“19 vs 8%”处“？8%”疑似有误，未做修改直接翻译）
