Rosansky Steven J, Schell Jane, Shega Joseph, Scherer Jennifer, Jacobs Laurie, Couchoud Cecile, Crews Deidra, McNabney Matthew
Dorn Research Institute, WJBD VA Hospital, Columbia, SC, USA.
Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, USA.
BMC Nephrol. 2017 Jun 19;18(1):200. doi: 10.1186/s12882-017-0617-3.
Dialysis initiation rates among older adults, aged 75 years or greater, are increasing at a faster rate than for younger age groups. Older adults with advanced CKD (eGFR < 30 ml/min/1.73 m) typically lose renal function slowly, often suffer from significant comorbidity and thus may die from associated comorbidities before they require dialysis.A patient's pattern of renal function loss over time in relation to their underlying comorbidities can serve as a guide to the probability of a future dialysis requirement. Most who start dialysis, initiate treatment "early", at an estimated glomerulofiltration rate (eGFR) >10 ml/min/1.73 m and many initiate dialysis in hospital, often in association with an episode of acute renal failure. In the US older adults start dialysis at a mean e GFR of 12.6 ml/min/1.73 m and 20.6% die within six months of dialysis initiation. In both the acute in hospital and outpatient settings, many older adults appear to be initiating dialysis for non-specific, non-life threatening symptoms and clinical contexts. Observational data suggests that dialysis does not provide a survival benefit for older adults with poor mobility and high levels of comorbidity. To optimize the care of this population, early and repeat shared decision making conversations by health care providers, patients, and their families should consider the risks, burdens, and benefits of dialysis versus conservative management, as well as the patient specific symptoms and clinical situations that could justify dialysis initiation. The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient's unique goals and priorities.In conclusion, when considering the morbidity and quality of life impact associated with dialysis, many older adults may prefer to delay dialysis until there is a definitive indication or may opt for conservative management without dialysis. This approach can incorporate all CKD treatments other than dialysis, provide psychosocial and spiritual support and active symptom management and may also incorporate a palliative care approach with less medical monitoring of lab parameters and more focus on the use of drug therapies directed to relief of a patient's symptoms.
75岁及以上老年人的透析起始率增长速度快于年轻人群体。患有晚期慢性肾脏病（估算肾小球滤过率[eGFR]<30 ml/min/1.73 m²）的老年人通常肾功能丧失缓慢，常伴有严重的合并症，因此可能在需要透析之前就死于相关合并症。患者肾功能随时间的丧失模式与其潜在合并症相关，可作为未来是否需要透析的概率指南。大多数开始透析的患者是在估算肾小球滤过率（eGFR）>10 ml/min/1.73 m²时 “早期” 开始治疗，许多患者在医院开始透析，通常与急性肾衰竭发作有关。在美国，老年人开始透析时的平均eGFR为12.6 ml/min/1.73 m²，20.6% 的患者在开始透析后的六个月内死亡。在急性住院和门诊环境中，许多老年人似乎因非特异性、非危及生命的症状和临床情况而开始透析。观察数据表明，透析对行动不便且合并症严重的老年人没有生存益处。为了优化对这一人群的护理，医疗保健提供者、患者及其家属应尽早并反复进行共同决策对话，考虑透析与保守治疗的风险、负担和益处，以及可证明开始透析合理的患者特定症状和临床情况。应结合每个患者的独特目标和优先事项考虑透析治疗的潜在优缺点。总之，在考虑与透析相关的发病率和生活质量影响时，许多老年人可能更愿意推迟透析，直到有明确指征，或者可能选择不进行透析的保守治疗。这种方法可以纳入除透析之外的所有慢性肾脏病治疗方法，提供心理社会和精神支持以及积极的症状管理，还可以纳入姑息治疗方法，减少对实验室参数的医学监测，更多地关注使用旨在缓解患者症状的药物治疗。
