Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston MA; Department of Medicine, Division of Palliative Care, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Interventional Nephrology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston MA; Department of Medicine, Interventional Nephrology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
Semin Nephrol. 2023 Jan;43(1):151397. doi: 10.1016/j.semnephrol.2023.151397. Epub 2023 Aug 12.
In this review, we discuss common challenges at the interface between dialysis access planning, prognostication, and patient-centered decision making. Particularly for patients whose survival benefit from dialysis is attenuated by advanced age or other serious illness, knowing the potential complications and anticipated frequency of access procedures is essential for patients and families to be able to conceptualize what life on dialysis will look like. Although starting dialysis with a functioning graft or fistula is associated with reduced infection rates, mortality, hospitalizations, and cost compared with a central venous catheter, these benefits must be weighed against the chance that early access placement in an elderly or seriously ill patient is an unnecessary surgery because the chronic kidney disease never progresses, the patient dies before developing an indication to start dialysis, or, the patient prefers conservative kidney management over dialysis. Kidney palliative care is a growing subspecialty of nephrology focused on helping seriously ill patients navigate complex medical decisions, and may be useful for intensive goals-of-care discussions about treatment and access options for patients with limited anticipated survival because of age or other serious illness.
在这篇综述中，我们讨论了透析通路规划、预后和以患者为中心的决策之间的常见挑战。特别是对于那些因高龄或其他严重疾病而透析生存获益降低的患者，了解潜在并发症和预期的通路手术频率对于患者和家属能够想象出透析后的生活是至关重要的。虽然与中心静脉导管相比，在透析开始时使用功能良好的移植物或瘘管与降低感染率、死亡率、住院率和成本相关，但必须权衡这些益处，因为在老年或重病患者中早期放置通路可能是一种不必要的手术，因为慢性肾脏病从未进展，患者在出现开始透析的指征之前死亡，或者患者更喜欢保守的肾脏管理而不是透析。肾脏姑息治疗是肾脏病学的一个新兴亚专科，专注于帮助重病患者做出复杂的医疗决策，对于因年龄或其他严重疾病而预期寿命有限的患者的强化目标治疗和通路选择的治疗方案的讨论可能是有用的。
