Berman Nathaniel
aWeill Cornell Medical College bRogosin Institute, New York, New York, USA.
Curr Opin Support Palliat Care. 2014 Dec;8(4):371-7. doi: 10.1097/SPC.0000000000000097.
The population considered eligible for dialysis has expanded dramatically over the past 4 decades, so that a significant proportion of patients receiving renal replacement therapy are elderly, frail and infirm. These patients have an extremely limited life expectancy and suffer from significant symptom burden, similar to patients with other end-stage organ failure or cancer. As dialysis has been offered more broadly, it is now initiated earlier than in decades past, further adding to cost and patient burden.
The trend toward more expansive and intensive care has not been corroborated by robust data. In response, an increasing number of studies has focused on establishing reasonable limits to renal replacement therapy. Multiple authors have explored the role of conservative kidney management for high-risk dialysis patients as an alternative to dialysis, which may offer similar survival and improved quality of life in certain populations. For those who chose dialysis, deferring initiation until the patient becomes symptomatic may be a reasonable. Evidence-based symptom management guidelines for dialysis patients remain largely absent, with few proven approaches. Hospice and palliative care resources remain underutilized.
For a subset of dialysis patients, palliative care and conservative kidney management are appropriate and underutilized.
在过去40年里，被认为适合透析的人群显著扩大，以至于接受肾脏替代治疗的患者中有很大一部分是老年人、体弱多病者。这些患者的预期寿命极其有限，且承受着巨大的症状负担，这与其他终末期器官衰竭或癌症患者相似。随着透析的应用范围越来越广泛，现在开始透析的时间比几十年前更早，这进一步增加了成本和患者负担。
越来越广泛和强化治疗的趋势并未得到有力数据的证实。作为回应，越来越多的研究致力于为肾脏替代治疗设定合理的限制。多位作者探讨了对高风险透析患者采用保守肾脏管理作为透析替代方案的作用，这在某些人群中可能提供相似的生存率并改善生活质量。对于那些选择透析的患者，推迟开始透析直到患者出现症状可能是合理的。透析患者基于证据的症状管理指南在很大程度上仍然缺乏，经过验证的方法很少。临终关怀和姑息治疗资源仍未得到充分利用。
对于一部分透析患者，姑息治疗和保守肾脏管理是合适的，但未得到充分利用。
Zotero 插件