Factors Affecting Survival in Advanced Chronic Kidney Disease Patients Who Choose Not to Receive Dialysis

Introduction. Non-dialytic treatment (NDT) has become a recognized and important modality of treatment in end stage renal disease (ESRD) in certain groups of chronic kidney disease (CKD) patients. However, little is known about the prognosis of these NDT patients in terms of hospitalization rates and survival. We analyzed our experience in managing these NDT with a multidisciplinary team (MDT) approach over a three-year period. Patients and Methods. The Renal Unit at the Royal Liverpool University Hospital set up a dedicated MDT clinic to manage NDT patients in January 2003. Patients approaching end stage chronic kidney disease who chose not to dialyse were recruited from other nephrologists. The study group was classified according to age band (<70 years, 71–80 years, and >80 years), estimated glomerular filtration rate (eGFR) (<10 ml/min, 11–20 ml/min, and >20 ml/min) according to the Modified Diet In Renal Disease formula and Stoke comorbidity grade (SCG). The SCG is a validated scoring system for the survival of patients on renal replacement therapy. We also used the ERA-EDTA primary renal diagnosis codes. As there are no existing standards for NDT patients, we used the U.K. national set for haemodialysis patients as a reference and target for our NDT patients. Data was collected prospectively. Results. The median age was 79 years and the male: female ratio was approximately 1. The most common primary cause of kidney disease in the NDT study population was chronic renal failure of unknown cause n = 22 (31%), but the most common identifiable cause was diabetic nephropathy, n = 20 (28%). The most common comorbidity was ischaemic heart disease n = 25 (34%). Those achieving the standards for anaemia were 78% at referral. Only 30% of the NDT patients achieved the standard for blood pressure (<130/80 mmHg) at referral. Forty-three patients (60%) had no admissions at all. There were a total of 30 patients admitted on 58 occasions. Thirty-one (53%) of these were due to a non-renal cause. The median length of stay for the other NDT patients was 10 days. The median overall survival (life expectancy) was 1.95 years. The one-year overall survival was 65%. SCG was an independent prognostic factor in predicting survival in NDT patients studied (p = 0.005), the hazard ratio being 2.53, for each incremental increase in the SCG. At one year, the survival for comorbidity grade 0, 1 and 2 were 83%, 70% and 56% respectively. Of the 28 patients who died, 20 did so at home (71%). Discussion. The NDT of ESRD has become an important alternative modality in renal replacement therapy. With the emergence of epidemic proportions of CKD, more elderly patients with progressive renal disease will need to make informed decisions regarding renal replacement therapy. There is likely to be increasing number of elderly patients that will tolerate dialysis badly and who will be very dependent on others. We believe that there should be a multidisciplinary approach to assist the ESRD patients in choosing their modality of renal replacement therapy, and with an agreed care plan to support these patients in managing their chosen modality to achieve the best possible quality of life. There should be integrated services with primary care, community nurses, and palliative care teams to enable the majority of the patient's treatment to be carried out at home and to allow a dignified death. However. there was a statistically significant trend for shorter survival among those with greater comorbidities, as determined by the SCG. This is the first report of the potential importance of SCG as an independent prognostic factor in NDT patients. This will help us to counsel our patients in the future about their prognosis if they choose NDT as their modality of renal replacement therapy. Conclusion. Our prospective study is the first and currently the largest observational study of a multidisciplinary approach in the management of NDT patients. SCG was an independent prognostic factor in predicting survival. In those patients who chose not to dialyse, SCG provides a potentially useful indication of expected prognosis.     

点穴配合机械辅助排痰对卒中相关性肺炎患者康复的影响

目的观察手指点穴配合机械辅助排痰对卒中相关性肺炎患者康复的影响。方法将46例卒中相关性肺炎患者随机分为治疗组22例和对照组24例。治疗组采用手指点穴配合机械辅助排痰治疗,对照组采用单纯机械辅助排痰治疗。比较两组治疗前后患者简化临床肺部感染评分(CPIS评分)、运动功能(Fugl-Meyer评分)及日常生活能力(改良Barthel指数)。结果两组患者治疗后CPIS量表评分、Fugl-Meyer评分及改良Barthel指数与同组治疗前比较,差异均具有统计学意义(P<0.01)。治疗组治疗后CPIS量表评分、Fugl-Meyer评分及改良Barthel指数与对照组比较,差异均具有统计学意义(P<0.05)。两组患者治疗后CPIS量表评分与Fugl-Meyer评分呈负相关性,CPIS量表评分与改良Barthel指数也呈负相关性。结论手指点穴配合机械辅助排痰能有效改善卒中相关性肺炎患者的肺部症状,有利于卒中患者的康复。     

“烧山火、透天凉”补泻脉法对中风恢复期下肢痉挛的影响

目的:观察"烧山火、透天凉"补泻蹻脉法对中风恢复期下肢痉挛的影响.方法:将180例患者随机分为两组,各90例,实验组采用"烧山火、透天凉"补泻蹻脉法即泻阴补阳蹻脉法治疗,对照组采用传统体针法治疗,两组均治疗28天,应用Ashworth量表,对首次治疗前0.5h,治疗后0.5、1、2、4、8h和28天分别测定患者的下肢肌痉挛,并观察疗效.结果:总有效率实验组82.4%,对照组75.6%;首次治疗后0.5h痉挛改善最明显(P<0.01或P<0.05),且实验组优于对照组(P<0.05);实验组在治疗后1h痉挛改善明显(P<0.05);两组治疗后28天痉挛改善均明显(P<0.01或P<0.05),且实验组优于对照组(P<0.05).结论:"烧山火、透天凉"补泻蹻脉法在近、远期内有效的降低中风恢复期患者患侧下肢肌痉挛.     

透刺法治疗中风后遗症的临床效果观察

目的:研究治疗中风后遗症的有效方法。方法:将120例中风后遗症患者随机分为透刺组(65例)和对照组(55例),透刺组采用透刺法治疗,对照组采用常规针刺法治疗。结果:透刺法能明显改善患者的神经功能缺损程度。透刺组总有效率92.31%,对照组总有效率70.26%,经统计学处理(P<0.01),差异有统计学意义。结论:采用透刺法治疗中风后遗症有更好的临床疗效。     

急性缺血性脑卒中选择性动脉内溶栓治疗患者肝素封管液浓度的探讨

目的：探讨选择性动脉内溶栓治疗术后患者套管针留置期间3种浓度肝素液封管对凝血功能的影响。方法：将60例选择性动脉内溶栓治疗患者随机分为三组,分别用62．5IU／ml、83IU／ml、125IU／ml浓度的肝素液封管,检测使用后凝血酶原时间（PF）、部分凝血活酶时间（APTT）及纤维蛋白原（FBG）,同时观察留置针的保留效果。结果：3种浓度的肝素封管液对PTT、APTT、FBC均无明显影响（P〉0．05）,其中83IU／ml浓度的肝素液封管不仅安全可行,而且能达到最佳导管效果,与另两组比较差异有统计学意义（P〈0．05）。结论：肝素浓度对选择性动脉内溶栓患者凝血功能无影响。83IU／ml浓度的肝素液封管保留效果好,是溶栓治疗患者使用留置针封管的最佳浓度。     

目标导向液体治疗对老年腰椎手术患者氧代谢和局部脑氧饱和度的影响

目的 探讨目标导向液体治疗对老年腰椎手术患者组织氧代谢和局部脑氧饱和度的影响。方法 选取2019年1月至2020年1月山西医科大学第二医院老年腰椎手术患者60例,年龄65~80岁,ASA分级II~III级,采用随机数字表法分为干预组和对照组,每组30例,干预组以每搏量变异度（SVV）、心指数（CI）为容量指标行目标导向液体治疗,对照组行常规液体治疗。于麻醉诱导前（T1）、手术开始时（T2）、手术开始后1小时（T3）、手术结束时（T4）、麻醉苏醒后30分钟（T5）,采集两组患者动脉血、中心静脉血行血气分析,记录两组患者总输入量、术中晶体液和胶体液用量、出血量、尿量、低血压出现次数、血红蛋白浓度（Hb）、乳酸含量（Lac）、中心静脉血氧饱和度（ScvO₂）及局部脑氧饱和度（rSO₂）,计算氧摄取率（O₂ER）。结果 与对照组比较,干预组晶体输入量、总液体输入量、尿量、低血压出现次数较低,差异有统计学意义（P<0.05）,干预组患者O₂ER、Lac较低,rSO₂、ScvO₂较高,差异有统计学意义（P<0.05）。结论 目标导向液体治疗有利于降低老年腰椎手术患者氧摄取率,维持脑氧供需平衡,改善全身组织氧代谢及微循环。     

早期针刺联合康复训练对急性脑梗死患者肢体功能的影响

目的观察早期针刺联合康复训练对急性脑梗死患者肢体功能的影响。方法将163急性脑梗死患者随机分为2组,治疗组82例予早期平阴补阳针刺法联合康复训练,对照组81例单纯予平阴补阳针刺法,2组均连续治疗4周。评定2组治疗前后欧洲卒中临床神经缺损(ESS)、简式Fugl-Meyer Assess-ment,FMA)评分及改良Barthel日常生活能力评定指数(BI)变化情况。结果 2组治疗后ESS、FMA及BI评分与本组治疗前比较均明显提高(P<0.05),且治疗组提高更明显(P<0.05)。结论早期针刺联合康复训练可最大限度地促进急性脑梗死后患者神经功能的恢复,改善肢体功能,提高生活质量。     

A Road Map of the Axial Spondyloarthritis Continuum

Axial spondyloarthritis (axSpA) is a chronic, immune-mediated inflammatory disease characterized by inflammatory low back pain, inflammation in peripheral joints and entheses, and other extra-articular or systemic manifestations. Although our understanding of the natural history of axSpA has been limited by incomplete knowledge of disease pathogenesis, axSpA is increasingly understood as a spectrum of axial, peripheral, and extra-articular inflammatory conditions that includes nonradiographic axSpA and radiographic axSpA, also known as ankylosing spondylitis. In this narrative review, we present a road map of this axSpA continuum, highlighting genetic risk factors for the development of axSpA, triggers of disease, and reasons for and implications of diagnostic delay. We present a detailed overview of the spectrum of axSpA clinical manifestations and highlight factors known to influence the risk of disease progression. Finally, we provide some expert commentary on the practical use of this road map to assist health care providers in the identification of axSpA in clinical practice.