Department of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom.
J Pain Symptom Manage. 2010 Sep;40(3):342-52. doi: 10.1016/j.jpainsymman.2010.01.021. Epub 2010 Jun 26.
There is little evidence on the symptoms experienced by those with advanced (Stage 5) chronic kidney disease (CKD), managed without dialysis, as they approach death. As palliative care extends to noncancer illnesses, understanding symptom prevalence and severity close to death will clarify which symptom interventions are most needed and which elements of (largely cancer-driven) models of palliative care best translate into end-of-life care for this population.
To determine symptom prevalence and severity in the last month of life for patients with Stage 5 CKD, managed without dialysis.
Longitudinal symptom survey in three U.K. renal units, using the patient-completed Memorial Symptom Assessment Scale-Short Form (MSAS-SF). We calculated the prevalence of individual symptoms (with 95% confidence intervals [CI] to reflect sample size), plus MSAS-SF subscales, in the month before death. Comparison is made with previously published data on symptoms in the last month of life in advanced cancer, also measured using the MSAS-SF.
Seventy-four patients (mean age: 81 years; standard deviation [SD]: 6.8) were recruited (response rate: 73%); 49 (66%) died during follow-up (mean age: 81 years; SD: 5.7). "Month before death" symptom data were available for 43 (88%) of the 49 participants who died. Median time of data collection was 18 days from death (interquartile range: 12-26 days). More than half had lack of energy (86%; 95% CI: 73%-94%), itch (84%; 70%-93%), drowsiness (82%; 68%-91%), dyspnea (80%; 66%-90%), poor concentration (76%; 61%-87%), pain (73%; 59%-85%), poor appetite (71%; 57%-83%), swelling arms/legs (71%; 57%-83%), dry mouth (69%; 55%-82%), constipation (65%; 50%-78%), and nausea (59%; 44%-73%). Levels of distress correspond to prevalence, with the exception of dyspnea, which was disproportionately more distressing. The median number of symptoms reported was 16.6 (range: 6-27), rising to 20.4 (range: 7-34) if additional renal symptoms were included. On average, psychological distress was moderate (mean MSAS-PSYCH: 1.55) but with wide variation (SD: 0.50; range: 0.17-2.40), suggesting diverse levels of individual distress. The prevalence of both physical and psychological symptoms and the number reported were higher than those in advanced cancer patients in the month before death.
Stage 5 CKD patients have clinically important physical and psychological symptom burdens in the last month of life, similar or greater than those in advanced cancer patients. Symptoms must be addressed through routine symptom assessment, appropriate interventions, and with pertinent models of end-of-life care.
对于未经透析治疗的晚期（第 5 阶段）慢性肾脏病（CKD）患者，他们在接近死亡时经历的症状证据很少。随着姑息治疗扩展到非癌症疾病，了解接近死亡时的症状普遍性和严重程度将明确哪些症状干预措施最需要，以及姑息治疗的哪些元素（主要由癌症驱动）最能转化为该人群的临终关怀。
确定未经透析治疗的第 5 阶段 CKD 患者在生命的最后一个月中症状的普遍性和严重程度。
在英国的三个肾脏单位进行了纵向症状调查，使用患者完成的 Memorial Symptom Assessment Scale-Short Form（MSAS-SF）。我们计算了在死亡前一个月中各个症状（95%置信区间[CI]以反映样本大小）的普遍性，以及 MSAS-SF 子量表的普遍性。并与先前发表的关于晚期癌症患者在生命最后一个月中症状的研究进行了比较，这些数据也是使用 MSAS-SF 测量的。
共招募了 74 名患者（平均年龄：81 岁；标准差[SD]：6.8）；49 名（66%）在随访期间死亡（平均年龄：81 岁；SD：5.7）。在 49 名死亡患者中，有 43 名（88%）可获得“死亡前一个月”的症状数据。数据收集的中位时间距离死亡 18 天（四分位距：12-26 天）。超过一半的患者有乏力（86%；95%CI：73%-94%）、瘙痒（84%；70%-93%）、嗜睡（82%；68%-91%）、呼吸困难（80%；66%-90%）、注意力不集中（76%；61%-87%）、疼痛（73%；59%-85%）、食欲不佳（71%；57%-83%）、手臂/腿部肿胀（71%；57%-83%）、口干（69%；55%-82%）、便秘（65%；50%-78%）和恶心（59%；44%-73%）。与普遍性相比，痛苦水平也相应较高，除了呼吸困难，其比例不成比例地更高。报告的症状中位数为 16.6（范围：6-27），如果包括额外的肾脏症状，则上升至 20.4（范围：7-34）。平均而言，心理困扰处于中度（平均 MSAS-PSYCH：1.55），但存在较大差异（SD：0.50；范围：0.17-2.40），表明个体的痛苦程度各不相同。在生命的最后一个月中，身体和心理症状的普遍性和报告数量均高于晚期癌症患者。
第 5 阶段 CKD 患者在生命的最后一个月中存在明显的身体和心理症状负担，与晚期癌症患者相似或更大。必须通过常规症状评估、适当的干预措施以及相关的临终关怀模式来解决这些症状。
