预透析诊所患者的治疗结果及其对共同决策的影响。

Outcomes of patients in a pre-dialysis clinic and implications for shared decision making.

作者信息

O'Keeffe Hannah, Donne Rosemary, Kalra Philip A, Ali Ibrahim

机构信息

Renal Department, Salford Royal Hospital, Northern Care Alliance, Manchester, United Kingdom.

Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.

出版信息

Clin Kidney J. 2025 Jul 8;18(8):sfaf211. doi: 10.1093/ckj/sfaf211. eCollection 2025 Aug.

DOI:10.1093/ckj/sfaf211

PMID:40755968

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12314264/

Abstract

BACKGROUND

The association of end-stage kidney disease (ESKD) with poor outcomes is well recognized. Education and discussions with patients with advanced chronic kidney disease (CKD) are important to facilitate shared decision making regarding care.

METHODS

This study reports longitudinal follow-up of all patients who attended the Advanced Kidney Care Service (AKCS) in a tertiary renal centre in the UK. Patients are routinely referred to AKCS once their estimated glomerular filtration rate (eGFR) drops below 20 mL/min/1.73 m. A total of 1957 patients who first attended between September 2011 and September 2018 were included, with a minimum of 5 years follow-up to 30 September 2023.

RESULTS

During follow-up, 55.7% of the cohort commenced renal replacement therapy (RRT), the initial modality was haemodialysis in 57.2%, peritoneal dialysis in 27.3% and a pre-emptive transplant in 15.5%, of which 42.6% were from live donors. Conservative management was chosen by 17.9% of patients. Of those who had opted for RRT, 26.7% died before reaching it. The 5-year survival was 49.6% from first attendance at AKCS. The 5-year survival rates by age group were: <50 years, 84.2%; 50-64 years, 66.1%; 65-79 years, 40.1%; and ≥80 years, 22.3% (< .001). The 5-year survival on haemodialysis was 49.6%, peritoneal dialysis 54.7% and 92.3% for pre-emptive transplant 92.3%. For those over 80 years of age a modest survival benefit was seen with RRT, with a median survival of 17.4 months from RRT commencement, compared with 11.8 months once the eGFR declined below 10 mL/min/1.73 m in the conservative group.

CONCLUSION

This study highlights the high competing mortality in an advanced CKD cohort. The high rates of pre-emptive transplantation and peritoneal dialysis initiation demonstrate the benefits of a structured AKCS strategy. Older patients with ESKD, particularly those aged over 80 years, have poor outcomes, regardless of whether they choose RRT or conservative management.

摘要

背景

终末期肾病（ESKD）与不良预后的关联已得到充分认识。对晚期慢性肾病（CKD）患者进行教育和讨论，对于促进有关治疗的共同决策很重要。

方法

本研究报告了在英国一家三级肾脏中心就诊的所有高级肾脏护理服务（AKCS）患者的纵向随访情况。一旦患者的估计肾小球滤过率（eGFR）降至20 mL/min/1.73 m²以下，就会常规转诊至AKCS。纳入了2011年9月至2018年9月首次就诊的1957例患者，至2023年9月30日至少随访5年。

结果

在随访期间，队列中的55.7%开始了肾脏替代治疗（RRT），初始治疗方式为血液透析的占57.2%，腹膜透析的占27.3%，预先移植的占15.5%，其中42.6%来自活体供体。17.9%的患者选择了保守治疗。在选择RRT的患者中，26.7%在开始治疗前死亡。从首次就诊于AKCS开始计算，5年生存率为49.6%。按年龄组划分的5年生存率分别为：＜50岁，84.2%；50 - 64岁，66.1%；65 - 79岁，40.1%；≥80岁，22.3%（P＜0.001）。血液透析的5年生存率为49.6%，腹膜透析为54.7%，预先移植为92.3%。对于80岁以上的患者，RRT有一定的生存获益，从开始RRT起的中位生存期为17.4个月，而保守治疗组中eGFR降至10 mL/min/1.73 m²以下后的中位生存期为11.8个月。