Reflections on end-of-life dialysis

ABSTRACT The world population is aging and diseases such as diabetes mellitus and systemic arterial hypertension are increasing the risk of patients developing chronic kidney disease, leading to an increase in the prevalence of patients on dialysis. The expansion of health services has made it possible to offer dialysis treatment to an increasing number of patients. At the same time, dialysis survival has increased considerably in the last two decades. Thus, patients on dialysis are becoming more numerous, older and with greater number of comorbidities. Although dialysis maintains hydroelectrolytic and metabolic balance, in several patients this is not associated with an improvement in quality of life. Therefore, despite the high social and financial cost of dialysis, patient recovery may be only partial. In these conditions, it is necessary to evaluate the patient individually in relation to the dialysis treatment. This implies reflections on initiating, maintaining or discontinuing treatment. The multidisciplinary team involved in the care of these patients should be familiar with these aspects in order to approach the patient and his/her relatives in an ethical and humanitarian way. In this study, we discuss dialysis in the final phase of life and present a systematic way to address this dilemma.

摘要 全球人口正步入老龄化阶段，糖尿病（diabetes mellitus）与系统性动脉高血压（systemic arterial hypertension）等疾病会升高患者罹患慢性肾脏病（chronic kidney disease）的风险，进而导致透析患者的患病率逐年攀升。医疗服务体系的扩容使得越来越多患者能够获得透析治疗。与此同时，近二十年来透析患者的生存期显著延长。由此，透析患者群体的规模持续扩大、年龄结构日趋偏高，合并症的数量也愈发增多。尽管透析可维持机体的水电解质与代谢平衡，但多数患者的生活质量并未因此得到改善。即便透析治疗的社会与经济成本高昂，患者的康复效果往往仅能实现部分缓解。在此情形下，需针对每位患者的透析治疗方案开展个体化评估，这需要对治疗的启动、维持或终止进行审慎考量。参与患者照护的多学科团队应熟知此类临床议题，以便以符合伦理与人道主义的方式与患者及其家属开展沟通。本研究探讨终末期生命阶段的透析治疗，并提出一套系统性方法以应对这一临床困境。