Octogenarians reaching end-stage renal disease:: Cohort study of decision-making and clinical outcomes
Octogenarians reaching end-stage renal disease:: Cohort study of decision-making and clinical outcomes
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DOI：
10.1097/01.asn.0000054493.04151.80
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发表时间：
2003-04-01
影响因子：
13.6
通讯作者：
Jungers, P
中科院分区：
文献类型：
--
作者：
Joly, D;Anglicheau, D;Jungers, P
达到终末期肾病(ESRD)的八旬老人的命运还不清楚，隐式透析配给可能在这个年龄段实行。本研究的主要目的是分析ESRD前的80岁老人是否接受透析治疗的特点，并找出影响透析期间死亡率的因素，以改善预后评估和决策。在这个单中心队列中，连续146名ESRD前的八旬老人在12年间(1989-2000)被转诊到肾脏内科。主要观察指标为接受透析和保守治疗的患者的基线特征，以及根据有效治疗进行的总生存期和1年生存率。对144例患者作出治疗决定。未建议透析组(n=37)与建议透析组(n=107)在社会隔离(43.3%比14.7%；P=0.03)、晚期肾病转诊(51.4%比28.9%；P=0.01)、卡氏评分(55+/-18比63 20；P=0.03)和糖尿病(22.2%与6.5%，P=0.008)方面存在差异。六名患者拒绝了透析提议。在12年的观察期内，99例患者死亡(68.7%)。接受透析的患者的中位生存期为28.9mo(95%CI，24~38)，而保守治疗的患者中位生存期为8.9mo(95%CI，4~10)(P<；0.0001)。在多变量分段Cox分析中，营养状况差、转诊晚和功能依赖是透析后1年内死亡的独立预测因素。包括在生存函数中，这些协变量预测低和高一年死亡率风险组。除接受透析治疗外，死亡的唯一独立预测因素是存在外周血管疾病。结论是，除了患者的个人拒绝，延迟转诊、社会隔离、低功能能力和糖尿病可能是导致相当大比例的ESRD前老年患者放弃透析的医疗决定的原因。虽然大多数接受透析的患者都经历了显著的生命延长，但在这个年龄段识别死亡预测因素应该会改善关于肾脏替代治疗预期益处的决策过程。
The fate of octogenarians reaching end-stage renal disease (ESRD) is poorly defined, and implicit dialysis rationing, may be practiced in this age group. The main objectives of this study were to analyze the characteristics of pre-ESRD octogenarians offered dialysis or not and to identify factors influencing mortality while on dialysis, to improve prognosis assessment and decision-making. In this single-center cohort, 146 consecutive pre-ESRD octogenarians were referred to a nephrology unit over a 12-yr period (1989 to 2000). Main outcome measures were baseline characteristics of patients offered dialysis and conservative therapy and overall and 1-yr survival according to effective treatment. A therapeutic decision was made for 144 patients. Octogenarians who were not proposed dialysis (n = 37) differed from those who were proposed dialysis (n = 107) mainly in terms of social isolation (43.3% versus 14.7%; P = 0.03), late nephrologic referral (51.4% versus 28.9%; P = 0.01), Karnofsky score (55 +/- 18 versus 63 20; P = 0.03), and diabetic status (22.2% verstis 6.5%, P = 0.008). Six patients refused the dialysis proposal. During the 12-yr observation period, 99 patients died (68.7%). Median survival was 28.9 mo (95% Cl, 24 to 38) in patients undergoing dialysis, compared with 8.9 mo (95% Cl, 4 to 10) in patients treated conservatively (P < 0.0001). In multivariable piecewise Cox analysis, independent predictors of death within 1 yr on dialysis were poor nutritional status, late referral, and functional dependence. Included in a survivor function, these covariates predict groups with low and high 1-yr mortality risk. Beyond I yr on dialysis, the only independent predictor of death was the presence of peripheral vascular disease. It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians . Although most patients on dialysis experienced a n substantial prolongation of life, identification of mortality predictors in this age group should improve the process of decision-making regarding the expected benefit of renal replacement therapy.