Brown Mark A, Collett Gemma K, Josland Elizabeth A, Foote Celine, Li Qiang, Brennan Frank P
Department of Renal Medicine, St. George Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia; and
Department of Renal Medicine, St. George Hospital, Sydney, Australia;
Clin J Am Soc Nephrol. 2015 Feb 6;10(2):260-8. doi: 10.2215/CJN.03330414. Epub 2015 Jan 22.
Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic.
Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL.
Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.
对于未接受透析治疗的老年晚期慢性肾脏病患者，其生存率、症状负担及生活质量尚不确定。我们对接受非透析肾脏支持治疗（RSC-NFD）的患者以及计划接受或开始透析的患者的这些结局进行了研究。
设计、地点、参与者及测量方法：在这项前瞻性观察性研究中，使用纪念症状评估量表和姑息治疗结局量表 - 症状（肾脏）问卷来测量症状，使用简短健康调查问卷-36来测量生活质量。本研究包括273名接受常规肾脏病护理的透析前患者以及122名非透析路径患者，这些非透析路径患者还就诊于一家增加了姑息医学团队技能的肾脏支持护理诊所。在此期间，另有72名患者未就诊于任何一家诊所而开始了透析治疗。
非透析患者比透析前组患者年龄更大（82岁对67岁；P<0.001），但在首次就诊时估算肾小球滤过率（eGFR）相似（16 ml/min/1.73 m²；P = 0.92）。在透析前患者中，92名（34%）开始了透析治疗。与RSC-NFD组相比，无需透析的透析前组患者死亡率较低（风险比，0.23；95%置信区间，0.12至0.41），需要透析的患者死亡率也较低（0.30；0.13至0.67），但未就诊于透析前诊所的透析患者死亡率不低（0.60；0.35至1.03）。RSC-NFD患者的中位生存期为16个月（四分位间距，9至37个月），32%的患者在eGFR降至低于10 ml/min/1.73 m²后存活超过12个月。对于整个研究组，年龄、血清白蛋白以及eGFR<15 ml/min/1.73 m²与较差的生存率相关。在非透析患者中，57%的患者在12个月内症状稳定或改善，58%的患者生活质量稳定或改善。
作为共同决策一部分而选择不进行透析的老年患者中位生存期为16个月，约三分之一的患者在本可能需要透析的时间点之后存活12个月。利用姑息医学技能有助于在不进行透析的情况下实现合理的症状控制和生活质量。
