Division of Nephrology, Stanford University School of Medicine, Palo Alto, California 94304, USA.
Kidney Int. 2012 Aug;82(3):261-9. doi: 10.1038/ki.2011.384. Epub 2011 Nov 16.
It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.
由于老年终末期肾病患者的合并症更多，预期寿命比临床试验或实践指南中描述的患者更短，因此，综合有关推荐管理策略的风险和获益信息往往较为困难。在这篇综述中，我们概述了一个框架，用于对老年终末期肾病患者的管理决策进行个体化处理。该框架考虑了三个因素：预期寿命、竞争治疗策略的风险和获益，以及患者偏好。我们通过将该框架应用于预期寿命不同的老年终末期肾病患者的三个关键决策，来说明该框架的应用：透析方式的选择、血液透析血管通路的选择，以及肾脏移植的转诊。在某些情况下，这种方法可能为与现有实践指南直接冲突的治疗决策提供支持，说明了在某些情况下，严格应用指南可能不适合某些患者。通过将获益和危害的定量估计与患者偏好的定性评估相结合，临床医生可能能够更好地为每个老年患者定制治疗建议，从而提高终末期肾病护理的整体质量。
