Javier Andrei D, Figueroa Rocio, Siew Edward D, Salat Huzaifah, Morse Jennifer, Stewart Thomas G, Malhotra Rakesh, Jhamb Manisha, Schell Jane O, Cardona Cesar Y, Maxwell Cathy A, Ikizler T Alp, Abdel-Kader Khaled
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
Division of Nephrology, University of New Mexico, Albuquerque, NM.
Am J Kidney Dis. 2017 Jul;70(1):93-101. doi: 10.1053/j.ajkd.2016.11.025. Epub 2017 Feb 15.
Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown.
Observational study.
SETTING & PARTICIPANTS: 388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic.
Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.
Mortality, test-retest reliability, and blinded inter-rater reliability.
Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin).
Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary).
Single center, small number of deaths.
The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.
预后的不确定性是慢性肾脏病（CKD）中开展照护目标讨论的一个障碍。意外问题（“如果该患者在未来12个月内死亡，你会感到意外吗？”）是一种辅助预后判断的工具。然而，它尚未在非透析依赖型CKD中进行研究，其可靠性也未知。
观察性研究。
388例年龄至少60岁、处于非透析依赖型CKD 4至5期的患者，这些患者来自门诊肾病科。
三元（即“是”“中立”或“否”）和二元（“是”或“否”）意外问题回答。
死亡率、重测信度和盲法评定者间信度。
基线合并症、查尔森合并症指数、CKD病因以及基线实验室值（即血清肌酐/估算肾小球滤过率、血清白蛋白和血红蛋白）。
患者中位年龄为71岁，中位随访时间为1.4年，在此期间52例（13%）患者死亡。使用三元意外问题时，医疗服务提供者分别对202例（52%）、80例（21%）和106例（27%）患者回答“是”“中立”和“否”。回答“是”“中立”和“否”的患者中分别约有5%、15%和27%死亡（P<0.001）。三元意外问题评定者间信度为0.58（95%CI，0.42 - 0.72），重测信度为0.63（95%CI，0.54 - 0.72）。三元意外问题回答“否”的敏感度和特异度分别为55%和76%（95%CI分别为38% - 71%和71% - 80%）。二元意外问题的敏感度为66%（95%CI，49% - 80%；与三元问题相比P = 0.3），但特异度较低，为68%（95%CI，63% - 73%；与三元问题相比P = 0.02）。
单中心研究，死亡病例数少。
意外问题与CKD 4至5期患者的死亡率相关，且显示出中度至良好的可靠性。未来研究应探讨如何最佳应用意外问题，以促进晚期非透析依赖型CKD的预先护理计划。
