Murphy Emma L, Murtagh Fliss E M, Carey Irene, Sheerin Neil S
Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK.
Nephron Clin Pract. 2009;111(1):c74-80. doi: 10.1159/000183177. Epub 2008 Dec 16.
It is often believed that patients with advanced chronic kidney disease (CKD) stage 4-5 have few symptoms, and that dying with renal disease is relatively symptom-free. But the symptom burden of patients managed conservatively (without dialysis), with potentially high levels of comorbidity and poor functional status, is unknown. This clinical audit evaluated the prevalence and severity of symptoms in conservatively managed CKD stage 4-5 patients.
Symptom data was collected from all conservatively managed patients from 2 renal units referred to a new renal palliative care service over a 10-month period between April 2005 and January 2006. Data on symptom prevalence and severity was collected as part of their routine clinical care, using a modified version of the Patient Outcome Scale--symptom module (POSs). This patient-completed instrument identifies the presence and severity of 17 symptoms. Demographic data was also collected, including estimated glomerular filtration rate (eGFR) using the MDRD formula, primary renal diagnosis and comorbidity.
Symptoms were evaluated in 55 patients, with a mean age of 82 years (SD 5.5, range 66-96). eGFR ranged from 3 to 30 ml/min (median 11, mean 12.75). In patients with CKD stage 4-5, managed without dialysis, the symptom burden is high. The most prevalent symptoms reported were weakness (75%), poor mobility (75%), poor appetite (58%), pain (56%), pruritus (56%) and dyspnoea (49%). The total number of symptoms each individual patient experienced ranged from 1 to 14 (median 7, mean 6.8). Symptoms were frequently reported as moderate, severe, or overwhelming; in 54% of patients with poor mobility, 48% with weakness, 30% with itching, 31% with anorexia and 27% with pain. No significant association was demonstrated between the number of symptoms experienced and either severity of renal disease or comorbidity score.
This structured clinical evaluation demonstrates the extent and severity of symptom burden in conservatively managed patients with CKD stage 4-5, and demonstrates the use of an appropriate clinical tool that can be used to assess the efficacy of treatment.
人们通常认为，晚期慢性肾脏病（CKD）4 - 5期患者症状较少，且死于肾病的过程相对没有症状。但对于保守治疗（不进行透析）、可能合并症水平高且功能状态差的患者，其症状负担尚不清楚。本次临床审计评估了保守治疗的CKD 4 - 5期患者症状的患病率和严重程度。
收集了2005年4月至2006年1月这10个月期间转至一项新的肾脏姑息治疗服务的2个肾脏科室所有保守治疗患者的症状数据。作为其常规临床护理的一部分，使用患者结局量表症状模块（POSs）的修改版收集症状患病率和严重程度的数据。该患者自填式工具可识别17种症状的存在及严重程度。还收集了人口统计学数据，包括使用MDRD公式估算的肾小球滤过率（eGFR）、原发性肾脏诊断和合并症情况。
对55例患者进行了症状评估，平均年龄82岁（标准差5.5，范围66 - 96岁）。eGFR范围为3至30 ml/分钟（中位数11，平均值12.75）。在未进行透析治疗的CKD 4 - 5期患者中，症状负担较重。报告最常见的症状为虚弱（75%）、活动能力差（75%）、食欲不佳（58%）、疼痛（56%）、瘙痒（56%）和呼吸困难（49%）。每位患者经历的症状总数为1至14种（中位数7，平均值6.8）。症状经常被报告为中度、重度或极为严重；活动能力差的患者中有54%、虚弱的患者中有48%、瘙痒的患者中有30%、食欲缺乏的患者中有31%以及疼痛的患者中有27%。所经历的症状数量与肾病严重程度或合并症评分之间未显示出显著关联。
这项结构化临床评估显示了保守治疗的CKD 4 - 5期患者症状负担的程度和严重性，并展示了一种可用于评估治疗效果的合适临床工具的应用。
