Gabbay Ezra, Meyer Klemens B
Division of Nephrology, Tufts Medical Center, Boston, MA, 02111 , USA.
NDT Plus. 2009 Apr;2(2):97-103. doi: 10.1093/ndtplus/sfn196. Epub 2008 Dec 22.
Clinicians treating critically ill patients must consider the possibility that painful and expensive aggressive treatments might confer negligible benefit. Such treatments are often described as futile or inappropriate. We discuss the problem of deciding whether to initiate renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI) in the context of the debate surrounding medical futility. The main problems in deciding when such treatment would be futile are that the concept itself is controversial and eludes quantitative definition, that available outcome data do not allow confident identification of patients who will not benefit from treatment and that the decision on RRT in a critically ill patient with AKI is qualitatively different from decisions on other modalities of intensive care and resuscitation, as well as from decisions on dialysis for chronic kidney disease. Despite these difficulties, nephrologists need to identify circumstances in which continued aggressive care would be futile before proceeding to initiate RRT.
治疗重症患者的临床医生必须考虑到，痛苦且昂贵的积极治疗可能带来微不足道的益处。此类治疗通常被描述为无效或不恰当。在围绕医疗无效性的辩论背景下，我们讨论了为患有急性肾损伤（AKI）的重症患者决定是否启动肾脏替代治疗（RRT）的问题。决定何时此类治疗无效的主要问题在于，该概念本身存在争议且难以进行量化定义；现有的预后数据无法让人们有把握地识别出那些不会从治疗中获益的患者；而且，对于患有AKI的重症患者，关于RRT的决策在性质上不同于关于其他重症监护和复苏方式的决策，也不同于关于慢性肾病透析的决策。尽管存在这些困难，但肾病学家在开始进行RRT之前，需要确定在哪些情况下继续积极治疗将是无效的。
