加拿大Calgary大學Libin心血管研究中心社區健康科學與內科部Brenda R. Hemmelgarn博士與Alberta腎臟病網絡的夥伴進行的研究,以中立的檢驗室檢視腎臟病盛行率和治療模式;居民都有接受省政府提供的全民醫療給付。密切監控發病率模式,包括長期腎臟透析和腎臟移植等腎臟替代治療方面沒有財務障礙。
  eGFR最低(15 - 29 mL/minute/1.73 m2)的這組,18-44歲者的腎衰竭治療比率是85歲以上者10倍多(每100人年校正比率分別是 24.00 [95%信心區間(CI),14.78 - 38.97] vs 1.53 [95% CI,0.59 - 3.99];P < .001)。
  反之,未治療腎衰竭的85歲以上患者,開始時的eGFR值15-29 mL/minute/1.73 m2則幾乎是18-44歲者的近11倍(每100人年校正比率分別是131.93[95% CI,116.62 - 149.27] vs 12.07 [95% CI,4.69-31.06];P < .001)。
  不過,澳洲雪梨皇家北岸醫院腎臟醫學主任Bruce A. Cooper博士表示,醫師不應太快建議長期腎臟透析。
  Cooper博士在2010年進行的「Initiating Dialysis Early and Late (IDEAL)」這個隨機臨床研究發現,腎臟透析可以延後約 6個月,直到病患的eGFR值降到7 mL/minute/1.73 m2但未影響病患的存活時。開始時的次組分析包括的風險因素年紀、開始時的eGFR、糖尿病、共病症,無法確認哪一組可以從提早開始進行透析中獲益( N Engl J Med. 2010;363:609-619)。
  Cooper博士在電話訪問中表示,Alberta研究的結果確認了廣泛接受的認知,腎功能隨年紀增長而降低。eGFR值30 mL/minute/1.73 m2對於85歲以上者可能是正常的。他指出,未提供長期腎臟透析給年長者,可能是因為沒有低eGFR之外的其他腎臟病證據。
  史丹佛大學的Manjula Kurella Tamura醫師和Wolfgang C. Winkelmayer醫師提出的編輯評論中,這反映出相當高層次的專業矛盾,令開業醫師和決策者對於85歲以上者的腎衰竭治療建立明確立場感到洩氣,編輯的意見則涵蓋了兩方的看法。

Kidney Failure Often Untreated in Patients Older Than 85

By James Brice
Medscape Medical News

June 19, 2012 — A study involving more than 1.8 million adults in Alberta, Canada, has uncovered an unexpectedly high incidence of untreated kidney failure among the elderly, suggesting the need for more clinical attention to the implications of chronic kidney disorders among extremely old patients.

The setting for the study, performed by Brenda R. Hemmelgarn, MD, PhD, from the Department of Medicine and the Department of Community Health Sciences and the Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada, and colleagues with the Alberta Kidney Disease Network, provided a natural laboratory for examining renal disease prevalence and treatment patterns. Residents are covered by universal healthcare provided by the Alberta provincial government. Morbidity patterns are closely monitored, and no financial barriers stand in way of renal replacement therapy, including long-term kidney dialysis and kidney transplantation.

The retrospective cohort study, which used laboratory and administrative data, included 1,816,824 Alberta residents aged 18 years or older who had at least 1 outpatient serum creatinine blood test between May 15, 2002, and March 31, 2008. Patients were followed-up for a median 4.4 years.

The study appears in the June 20 issue of JAMA.

Dr. Hemmelgarn and colleagues found that the rate of treated kidney failure was significantly lower among older patients than younger patients in every measure of estimated glomerular filtration rate (eGFR).

In the lowest eGFR stratum (15 - 29 mL/minute/1.73 m2), rates of treated kidney failure were more than 10 times higher for patients between 18 and 44 years of age than for patients who were at least 85 years of age (adjusted rate, 24.00 [95% confidence interval (CI), 14.78 - 38.97] vs 1.53 [95% CI, 0.59 - 3.99] per 1000 person years, respectively; P < .001).

Conversely untreated kidney failure among adults aged 85 years or older who had a baseline eGFR level of 15 to 29 mL/minute/1.73 m2 was nearly 11 times more common than in patients between 18 and 44 years of age (adjusted rate, 131.93 [95% CI, 116.62 - 149.27] vs 12.07 [95% CI, 4.69-31.06] per 1000 person-years, respectively; P < .001).

Previous studies established that the use of dialysis for kidney failure typically peaks by age 75 years and then decreases, although patients older than 65 years are the fastest growing segment of the population who are initiating dialysis, the authors note.

Inadequate Preparation for Dialysis

The researchers' findings suggest that many older adults with advanced chronic kidney disease are not adequately prepared for dialysis, and physicians may not adequate recognize clinically relevant kidney disease progression among their older patients. Assessments should become a priority, the authors write.

However, clinicians should not recommend long-term kidney dialysis too quickly, according to Bruce A. Cooper, MBBS, PhD, chief of renal medicine at Royal North Shore Hospital, Sydney, Australia, who was not involved with the Alberta study.

The randomized Initiating Dialysis Early and Late (IDEAL) clinical trial, led by Dr. Cooper in 2010, found that renal dialysis could be delayed about 6 months until the patient's eGFR level dropped to 7 mL/minute/1.73 m2 without affecting patient survival. A subanalysis of baseline risk factors including age, baseline eGFR, diabetes, and comorbidity was unable to identify any group that benefitted from an early start to dialysis ( N Engl J Med. 2010;363:609-619).

Findings from the Alberta study confirm the widely appreciated understanding that renal function naturally declines with advancing years, Dr. Cooper told Medscape Medical News in a telephone interview. An eGFR of 30 mL/minute/1.73 m2 may be normal for an individual older than 85 years, he said. Elderly patients may not be offered long-term kidney dialysis because there is no evidence of renal disease other than low eGFR, he added.

"eGFR should be used as guide for identifying potential renal disease, but we still need to look at the patient for other significant symptoms and biochemical derangements that would justify the need to start dialysis or the consideration of dialysis," Dr. Cooper said.

Professional Ambivalence

An accompanying editorial by nephrologists Manjula Kurella Tamura, MD, and Wolfgang C. Winkelmayer, MD, ScD, both from Stanford University in California, reflects the high level of professional ambivalence that has discouraged practitioners and policymakers from establishing a definitive position about kidney failure treatment for individuals older than 85 years. The editorialists' opinions covered both sides of the issue.

The rate of untreated kidney failure depends on how it is defined, but the rate reported in the Alberta trial is hard to dismiss, they write.

Whereas the magnitude of untreated kidney failure among older adults does not necessarily imply appropriate treatment has been withheld from this population, the option may have not been carefully considered because older patients usually only see nephrologists when the need for dialysis is imminent.

In the end, Dr. Tamura and Dr. Winkelmayer concluded that the time for vacillation must soon end.

"Finding the right balance between overtreatment and undertreatment is challenging but necessary," they note. "This important scientific and ethical debate can no longer be avoided, for both individual and societal good."

This work was supported by the Canadian Institute of Health Research and by an interdisciplinary team grant from Alberta Innovates–Health Solutions. Dr. Hemmelgam and several of the other authors were supported by career salary awards from Alberta Innovates–Health Solutions. Dr Hemmelgarn was supported by the Roy and Vi Baay Chair in Kidney Research, and a coauthor was supported by a Government of Canada Research Chair. Another coauthor is supported by Fellowship Awards from the Canadian Institute of Health Research and the Canadian Diabetes Association. One of the study authors reports receiving royalties from UpToDate, and one coauthor reports consulting for and receiving salary support through a grant to his institution by Amgen. Dr. Tamura has served as a scientific advisor to Amgen. Dr. Winkelmayer has served as a scientific adviser to Affymax/Takeda, Amgen, Fibrogen/Astellas, GlaxoSmithKline, and Vifor Fresenius Medical Care Renal Pharma Ltd. Dr. Cooper has disclosed no relevant financial relationships.

JAMA. 2012;307:2507-2515, 2545-2546.

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