Hong Kong Journal of Nephrology最新文献

Background/purpose

There is increasing recognition of the need to integrate advance care planning (ACP) into end-stage renal disease (ESRD) care with attention to medical, ethical, psychosocial, and spiritual issues but publications comparing patients who chose renal replacement therapy (RRT) and renal palliative care (RPC) is scarce. We here share our experience on ACP for ESRD patients in a center with renal replacement and palliative programs in place.

Methods

From June 2006 to December 2011, ESRD patients were empowered to make an informed choice of future medical care in a structured ACP that was emphasized to be an ongoing process. Patients who opted for RRT and RPC would be followed up at the predialysis clinic and the one-stop multidisciplinary RPC clinic, respectively. This was a single-center study in a secondary care hospital. A total of 600 patients (265 RRT, 335 RPC) were enrolled and followed up over a median of 782 days.

Results

The majority of patients and relatives declined dialysis because of perceived physical burden. Only 1.6% of palliative care patients changed their decision and commenced dialysis. Baseline characteristics differed between patients who chose RRT or RPC. Survival declined according to the modified Charlson Comorbidity Index scores. Older age, mental incompetence, hyperlipidemia, high modified Charlson Comorbidity Index, low estimated glomerular filtration rate, and low albumin were important independent predictors of poor survival. Factors affecting the ACP decision were discussed in the Chinese culture context.

Conclusion

A structured ACP could empower the patient to make an informed decision on the management of ESRD.

背景

於未期腎病患者的照顧中加入關注身心社靈和倫理問題的預設照顧計劃(ACP)受到日益重視，但有關比較接受腎替代療法和接受腎臟紓緩治療文獻討論為數不多。作為同時提供腎透析服務以及腎臟紓緩治療的部門，本文旨在分享我們為未期腎病者討論預計照顧計劃的經驗。

方法

自二零零六年六月至二零一零五月間，透過有組織的預設照顧計劃討論，未期腎病患者會被鼓勵就未來的治療計劃作出知情選擇。選擇腎透析和腎臟紓緩治療的病人會分別於透析預備門診和一站式跨科際腎臟紓緩治療門診去覆診。本研究於一家二級醫院進行。總共有六百病人參與此研究，當中265名接受腎透析，335名接受腎臟紓緩治療，其中位跟進日數為782日。

結果

大部份病人和家屬之所以拒絕腎透析是由於預計的身體負累，只有百分之一點六接受腎臟紓緩治療會改變主義而接受腎透析。選擇腎透析和腎臟紓緩治療的病人在基本的身體狀況有明顯分別。生存率亦隨著修改版查爾森共病量表的分數而下降。年長、精神自主能力缺欠、高血脂、修改版查爾森共病量表分數高、腎小球濾過率低、白蛋白低均屬重要暨獨立的因素以預計較差的生存率。本文亦會探討在中國文化處境下影響預設照顧計劃討論的因素。

結論

有組織的預設照顧計劃討論能幫助病人在未期腎病的醫療方向作出知情的選擇。

Background/purpose

With global socioeconomic development and improvement in the general health care system, life expectancy increases, resulting in an increasing incidence of end-stage renal disease in the elderly population. We compared the survival rate in elderly patients aged ≥ 65 years with Stage 5 chronic kidney disease, managed with either renal replacement therapy (RRT) or conservative treatment. We also tried to identify factors associated with survival in these two groups.

Methods

This is a single-center retrospective study of patients aged ≥ 65 years with Stage 5 chronic kidney disease, who were referred to the nephrology team for renal advance care planning to assist in decision making for RRT or conservative treatment from 2005 to 2013. They were followed up till death or till December 31, 2014. Baseline characteristics (demographics, clinical data, functional status, socioeconomic factors, and laboratory parameters) and mortality data between the two groups were compared.

Results

A total of 558 patients were recruited during the study period, in which 126 (22.6%) patients opted for RRT and 432 (77.4%) for conservative treatment. Patients with less significant comorbidities, lower modified Charlson's Comorbidity Index scores, better functional and mental statuses, as well as better socioeconomic status were more likely to choose RRT. The RRT group had a longer median survival of 44.6 months compared with 10.0 months in the conservative treatment group. The survival advantage of the RRT group was lost in patients older than 85 years, or in those with high comorbidity (modified Charlson's Comorbidity Index score of ≥11) or dependent mobility. Age, comorbidity, and mobility were predictors of mortality in the RRT group. For the conservative group, age, mobility, and sex were predictors of mortality.

Conclusion

Elderly patients with end-stage renal disease can be benefited from RRT. However, the survival advantage of RRT was lost in very-advanced-age patients older than 85 years of age, in those with high comorbidity, or in functionally dependent patients.

目的

在全球性的社會經濟發展下;預期壽命得以延長;導致在老年人口中;末期腎病的發生率亦有所增長。我們在 ≥ 65 歲的第 5 期慢性腎病年老患者間;比較了腎置換療法 (RRT) 與保守療法所達到的存活率。同時;我們亦嘗試找出影響這兩組病人存活的因素。

方法

這是一項單中心的回溯性研究;對象為 ≥ 65 歲的第 5 期慢性腎病患者。他們是在 2005 年至 2013 年期間;被轉介至腎科團隊接受預設照顧計劃;以協助他們選擇 RRT 或保守療法；追蹤期至 2014 年 12 月 31 日或病人去世為止。我們比較了兩組病人的基線特徵及死亡率數據。

結果

本研究共納入 558 位病人;其中 126 (22.6%) 人選擇了 RRT;432 (77.4%) 人選擇了保守療法。RRT 組的存活中位數為 44.6 個月;較保守療法組的 10.0 個月長。然而;在 >85 歲、共病顯著 (mCCI ≥ 11)、或不能獨立行動的病人中;RRT 的存活優勢消失。在 RRT 組中;年齡、共病、及行動力是死亡的預測因子,在保守療法組中;年齡、行動力、及性別是死亡的預測因子。

結論

年老末期腎病患者可以獲益於 RRT,然而;在 >85 歲的極高齡者、共病顯著者、或不能獨立行動的病人中;RRT 的存活優勢不復存在。

We herein present a case of an intrarenal pseudoaneurysm developing 2 weeks after renal transplantation. The patient presented with hemorrhagic shock. Computed tomography confirmed an intrarenal pseudoaneurysm with extravasation of contrast and a large surrounding hematoma. Angiography confirmed the pseudoaneurysm, and embolization of the segmental graft renal artery was performed. In view of the uncertain etiology and the possibility of a mycotic pseudoaneurysm, we administered empiric antimicrobial therapy. The clinical course, investigations, and management are described. Finally, a review of the literature regarding post-transplantation pseudoaneurysms is presented.

以下是一宗於移植後 2 週出現的腎內僞動脈瘤個案，患者以出血性休克表現。當時為其安排緊急電腦斷層攝影 (CT)，發現有一個腎內僞動脈瘤，並呈現顯影劑溢出現象，且被一大型血腫圍繞。緊急血管攝影證實為植入腎之僞動脈瘤，同時我們對涉及的節段性動脈予以栓塞處置。基於病因並不明確，而且不能排除黴菌性僞動脈瘤的可能性，因此我們實施了經驗性抗微生物學療法。在本文中，我們描述了本個案的臨床歷程、相關檢查及後續處置，並指出我們在治療上所遭遇到的困難。最後，我們對移植後僞動脈瘤的相關文獻作出了回顧。

Background/Purpose

The peritoneal membrane of long-term peritoneal dialysis (PD) patients is characterized by morphological and microvascular changes. It is said that lactate-based peritoneal dialysate is implicated in the development of these changes. The aim of this study is to compare the effects of long-term exposure to glucose-based, lactate-buffered (Dianeal), and biocompatible bicarbonate/lactate-buffered, low glucose degradation product (Physioneal) peritoneal solutions on the peritoneal membrane.

Methods

Thirty-nine incident PD patients were randomized into two groups: 19 patients with Dianeal dialysate (Group A) and 20 with biocompatible Physioneal dialysate (Group B). All patients used automated PD for a median of 31 months in Group A and 32 months in Group B. Three biopsies at one occasion only were taken from the peritoneal membrane at the end of the study. All samples were collected and fixed in accordance with a standardized protocol, and a histopathologist blinded to the clinical status and PD solutions allocated to the patients carried out the analysis.

Results

The commonest change observed was peritoneal fibrosis, seen in 35 out of 39 cases (89.7%); it was moderate to severe in 28 cases (71.8%) and mild in 11 (28.2%) cases. This was followed by loss of mesothelial cells (22 cases, 56.4%), elastosis (20 cases, 51.3%), increased blood vessels (15 cases, 38.5%), thick-walled blood vessels (10 cases, 25.6%), and finally chronic inflammation and mesothelial cell hyperplasia (7 cases, 17.9%, and 6 cases, 15.4%, respectively). Of the patients with blood vessel abnormalities, 22 (88.0%) exhibited significant fibrosis and only three (12.0%) did not. Of those without blood vessel changes, only six (42.9%) patients exhibited similar degree of fibrosis (p < 0.01). The prevalence of vascular changes, moderate to severe fibrosis, as well as mesothelial cell abnormalities increased as the duration of PD increased. The prevalence of fibrosis, mesothelial cell loss, and vascular abnormalities increased significantly with diabetes mellitus (p < 0.001).

Conclusion

There was no difference in the effects of long-term exposure to glucose-based, lactate-buffered, and biocompatible bicarbonate/lactate-buffered, low glucose degradation product peritoneal solutions on the peritoneal membrane. Risk factors other than PD dialysate composition need to be considered when assessing peritoneal membrane adequacy. The factors that were proved to be significant in our study are duration of end-stage renal disease, diabetes mellitus, and time on PD.

背景 / 目的

在接受長期腹膜透析 (PD) 的病人間，腹膜會出現若干的形態學與微血管變化，這些變化被認為與採用乳酸鹽腹膜透析液有關。本研究旨在比較兩種透析液的長期暴露—乳酸鹽緩衝之 Dianeal^®、與生物相容之 Physioneal^® 對病人腹膜的影響。

方法

共 39 位剛開始接受 PD 的病人被分為兩組：19 人接受 Dianeal 透析液 (A 組)、20 人接受生物相容之 Physioneal 透析液 (B 組)，所有病人接受的均為自動化 PD (APD