Renal and Metabolic Division, The George Institute for Global Health, Sydney, Australia.
Nephrol Dial Transplant. 2012 Sep;27(9):3581-7. doi: 10.1093/ndt/gfs096. Epub 2012 May 7.
Increasing numbers of elderly patients face decisions about the management of end-stage kidney disease. Improved understanding of contemporary patient and practice factors influencing prognosis may assist decision making for individual patients and their care providers.
This is a prospective registry study using multivariable proportional hazards models. A total of 1781 patients aged ≥ 75 years at dialysis initiation recorded in ANZDATA, the Australia and New Zealand renal replacement registry, between January 2002 and December 2005. The patient characteristics were demographic and comorbid conditions. The practice characteristics were late referral, access at dialysis initiation and intended dialysis modality (modality established by 90 days). The study outcome was mortality censored at 31 December 2007 or at recovery of renal function (of at least 30 days), transplantation or loss to follow-up.
Median follow-up was 2.3 years (interquartile range 1.1-3.3 years) during which time, 65% of the patients died. Baseline factors independently associated with mortality were older age [hazard ratio (HR) 1.24 for 5-year increase, 95% confidence interval (CI) 1.13-1.36], body mass index <18.5 (HR 1.78, 95% CI 1.33-2.38), number of comorbidities (one comorbidity HR 1.38, 95% CI 1.13-1.69; two comorbidities HR 1.55, 95% CI 1.27-1.89; three or more comorbidities HR 1.89, 95% CI 1.55-2.31), late referral (HR 1.19, 95% CI 1.02-1.39), peritoneal dialysis as intended modality (HR 1.26, 95% CI 1.08-1.47) and unprepared access (HR 1.43, 95% CI 1.23-1.67). The limitations of the study were the observational nature of the analysis, potential selection bias introduced through analysis of a group who actually commenced dialysis and the potential confounding from unmeasured factors or dichotomous reporting of comorbidities.
Within the elderly cohort, other patient characteristics have a greater association with mortality than 5-year age increments. Even after consideration of patient characteristics, practice factors have a striking impact on the survival of elderly patients commencing dialysis. In the absence of randomized studies, efforts to enhance the identification and preparation of elderly patients for dialysis may improve outcomes within current settings.
越来越多的老年患者面临终末期肾病治疗方案的选择。深入了解影响预后的当代患者和实践因素，可能有助于为患者及其护理人员做出个体决策。
这是一项使用多变量比例风险模型的前瞻性登记研究。共纳入了 2002 年 1 月至 2005 年 12 月期间，澳大利亚和新西兰肾脏替代登记处（ANZDATA）登记的 1781 名年龄≥75 岁的开始透析的患者。患者特征包括人口统计学和合并症情况。实践特征包括晚期转诊、开始透析时的通路和预期的透析方式（90 天内确定）。研究结果为 2007 年 12 月 31 日或肾功能恢复（至少 30 天）、移植或失访时的死亡率。
中位随访时间为 2.3 年（四分位距 1.1-3.3 年），在此期间，65%的患者死亡。与死亡率独立相关的基线因素包括年龄较大（每增加 5 年，风险比[HR]为 1.24，95%置信区间[CI]为 1.13-1.36）、体重指数<18.5（HR 为 1.78，95%CI 为 1.33-2.38）、合并症数量（一种合并症 HR 为 1.38，95%CI 为 1.13-1.69；两种合并症 HR 为 1.55，95%CI 为 1.27-1.89；三种或更多种合并症 HR 为 1.89，95%CI 为 1.55-2.31）、晚期转诊（HR 为 1.19，95%CI 为 1.02-1.39）、腹膜透析作为预期的方式（HR 为 1.26，95%CI 为 1.08-1.47）和准备不足的通路（HR 为 1.43，95%CI 为 1.23-1.67）。该研究的局限性在于分析的观察性质、通过分析实际开始透析的人群引入的潜在选择偏倚以及未测量因素或合并症的二分法报告带来的潜在混杂。
在老年队列中，其他患者特征与死亡率的相关性大于 5 年的年龄增长。即使考虑到患者特征，实践因素对开始透析的老年患者的生存也有显著影响。在没有随机研究的情况下，努力增强对老年患者的识别和准备，以接受透析治疗，可能会改善当前环境下的预后。
