Brunori Giuliano, Viola Battista Fabio, Maiorca Paolo, Cancarini Giovanni
Institute and Department of Nephrology, University and Spedali Civili of Brescia, Brescia, Italy.
Blood Purif. 2008;26(1):36-40. doi: 10.1159/000110561. Epub 2008 Jan 10.
Over the past decade the number of elderly patients reaching end-stage renal disease has more than doubled. A fundamental medical decision that nephrologists commonly have to make is when to start dialytic treatment in elderly patients. Evidence is needed to inform about decision-making for or against dialysis, in particular in those patients frequently affected by multiple comorbidities for which dialysis may not increase survival. In fact, this decision affects quality of life, incurs significant financial costs, and finally mandates use of precious dialysis resources. The negative consequence of initiating dialysis in this group of patients can be deleterious as elderly people are sensitive to lifestyle changes. Furthermore, among dialysis patients, the elderly suffer the highest overall hospitalization and complication rates and most truncated life expectancy on dialysis of any age group. Studies of the factors that affect outcomes in elderly patients on dialysis, or the possibility in postponing in a safe way the start of a dialytic treatment, were lacking until recent years. Recently in the literature, papers have been published that address these questions: the effects of dialysis on morbidity and mortality in elderly patients and the use of a supplemented very low protein diet (sVLPD) in postponing the start of dialysis in elderly. The first study demonstrated that, although dialysis is generally associated with longer survival in patients aged >75 years, those with multiple comorbidities, ischemic heart disease in particular, do not survive longer than those treated conservatively. The second one is a randomized controlled study that compared a sVLPD with dialysis in 112 non-diabetic patients aged >70 years. Survival was not different between the two groups and the number of hospitalizations and days spent in hospital were significantly lower in those on a sVLPD. These studies add to the limited evidence that is currently available to inform elderly patients, their carers and their physicians about the risk and the benefit of dialysis.
在过去十年中，达到终末期肾病的老年患者数量增加了一倍多。肾病学家通常必须做出的一个基本医疗决策是何时开始对老年患者进行透析治疗。需要证据来为支持或反对透析的决策提供依据，尤其是在那些经常受到多种合并症影响的患者中，透析可能不会提高生存率。事实上，这一决策会影响生活质量，产生巨大的经济成本，最终还需要使用宝贵的透析资源。在这类患者中开始透析的负面后果可能是有害的，因为老年人对生活方式的改变很敏感。此外，在透析患者中，老年人的总体住院率和并发症发生率最高，并且在任何年龄组中，他们在透析时的预期寿命最短。直到近年来，才开始有关于影响老年透析患者预后的因素，或安全推迟开始透析治疗可能性的研究。最近在文献中发表了一些论文，探讨了这些问题：透析对老年患者发病率和死亡率的影响，以及使用补充性极低蛋白饮食（sVLPD）来推迟老年患者开始透析的情况。第一项研究表明，虽然透析通常与75岁以上患者的较长生存期相关，但那些患有多种合并症，尤其是缺血性心脏病的患者，其生存期并不比接受保守治疗的患者更长。第二项是一项随机对照研究，比较了112名70岁以上非糖尿病患者接受sVLPD与透析的情况。两组的生存率没有差异，接受sVLPD的患者的住院次数和住院天数明显更低。这些研究为目前有限的证据增添了内容，这些证据可用于告知老年患者、他们的护理人员和医生透析的风险和益处。
