Li Kelly Chenlei, Brown Mark Ashley
Renal Department, St George Hospital, University of New South Wales, Sydney, Australia.
Renal Department, St George Hospital, University of New South Wales, Sydney, Australia.
Semin Nephrol. 2023 Jan;43(1):151395. doi: 10.1016/j.semnephrol.2023.151395. Epub 2023 Jul 22.
Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.
对于老年或重症肾衰竭患者而言，在透析和保守肾脏管理（CKM）之间做出抉择十分复杂，需要共同决策。患者及其家属期望肾病专家能给出符合以患者为中心目标的个性化建议。为了做出平衡且周全的决策，透析不应成为默认选项，肾病专家需要熟悉相关的预后信息，包括生存率、症状负担、功能轨迹以及透析和CKM状态下的生活质量。CKM是一种针对肾衰竭的全面、积极且多学科的治疗方法。对于一些患有多种合并症的老年患者，CKM可减轻症状负担，符合生活质量目标，且寿命仅有轻微缩短或不受影响。CKM可由肾病专家单独提供，但理想情况下应通过与肾病科内部专门的支持或姑息治疗服务合作来进行管理。治疗决策最好在疾病进程早期进行讨论，且需经过多次会诊，肾病专家应提升沟通技能，以便在这些重要谈话中更好地支持患者及其家属。肾病专家应持续积极参与患者的治疗直至临终关怀阶段。
