Estimating prognosis in end-stage renal disease

摘要

Studies show that most patients with end-stage renal disease (ESRD) who are receiving dialysis want to talk about their life expectancy. Yet over half of patients have never had such a conversation. The three main reasons for this are: (i) staff's lack of training in communication; (ii) a mistaken belief that thoughtful discussion of poor prognosis will extinguish hope; and (iii) uncertainty about the accuracy of available prognostic tools. Current methods for formulating a prognosis include: (i) the Surprise Question (SQ); (ii) use of various actuarial indices such as the Charlson Co-morbidity Index (CCI); and (iii) a combination of these. In the SQ, clinical staff are asked whether they would be surprised if their patient died within the next 6 months to one year. A 'no' answer identifies a high-risk group with an odds ratio (OR) of dying of 3.5. Actuarial indices using such factors as age, gender, type of vascular access, serum albumin, and performance of activities of daily living have also identified subgroups with an increased OR. Since over half of deaths in dialysis patients stem from cardiovascular causes, these indices should also be considered, and they include: functional cardiac classification, a history or occurrence of myocardial infarction, congestive heart failure, progression of left ventricular hypertrophy and inclusion of biomarkers such as an elevated cardiac troponin T (cTNT). Training in communication about prognosis combined with the use of intuitive measures and refined actuarial indices should decrease the gap between patient's desire for prognostic information and caregiver's willingness and ability to provide this information.