Douglas C A
CA Douglas, Cornhill Macmillan Centre, Perth Royal Infirmary, Jeanfield Road, Perth PH1 1NX, UK. Email
J R Coll Physicians Edinb. 2014;44(3):224-31. doi: 10.4997/JRCPE.2014.309.
Over the past three decades there has been a dramatic rise in the number of patients with advanced chronic kidney disease. The fastest expanding group receiving dialysis has been the elderly. However, for those patients who are very elderly with co-morbidity, dialysis may not offer a survival advantage. Therefore, active conservative management is a growing service offered by many renal units in the UK and focuses on non-dialytic correction of fluid and electrolyes, management of renal anaemia, and assessment and management of symptoms. The five-year survival of a patient over 75 years of age starting dialysis is 20% and if a patient is over 75 years, has co-morbidity, or a poor performance status, dialysis may not offer any survival advantage. Whether a patient is managed by dialysis or by conservative management the symptom burden suffered is high. These symptoms are under-recognised and often managed poorly because of increased drug toxicity in renal failure. This complex group of patients require close working between renal, palliative care, medicine for the elderly, and community teams, to allow best quality of life and end of life care. This review describes some of the challenges in providing Advanced Care Planning for dialysis and conservatively managed patients, highlights the symptom burden of patients with advanced chronic kidney disease, and offers guidance in how to manage the symptoms effectively.
在过去三十年中，晚期慢性肾病患者的数量急剧上升。接受透析的增长最快的群体是老年人。然而，对于那些患有合并症的高龄患者，透析可能无法带来生存优势。因此，积极的保守治疗是英国许多肾脏科室日益提供的一项服务，其重点在于对液体和电解质进行非透析纠正、管理肾性贫血以及评估和管理症状。开始透析的75岁以上患者的五年生存率为20%，如果患者年龄超过75岁、患有合并症或身体状况不佳，透析可能无法带来任何生存优势。无论患者接受透析治疗还是保守治疗，其所承受的症状负担都很高。这些症状未得到充分认识，且由于肾衰竭时药物毒性增加，往往处理不当。这类复杂的患者群体需要肾脏科室、姑息治疗团队、老年医学团队和社区团队密切合作，以实现最佳生活质量和临终关怀。本综述描述了为接受透析和保守治疗的患者提供高级护理计划时面临的一些挑战，强调了晚期慢性肾病患者的症状负担，并就如何有效管理这些症状提供了指导。
