2015 KDOQI 血液透析治療指引,關於1.2的討論:
一、開始透析的時機:
1.2 何時開始洗腎(透析),最主要的三個決定因素,在於是否出現了尿毒症狀、是否有營養不良、以及是否有能力維持各項生理機能(如電解質的平衡、或體液過多)這三個因素。抽血數值中的毒素高低,並不是開始洗腎於否的決定性因素。
一般來說,抽血報告中用來看毒素高低、以及判斷剩餘腎臟功能的多寡的指標,就是血中的肌酸酐,用這個指標來換算腎絲球過濾速率,然而,這個指標常會受很多因素影響:
肌酸酐增加的情況(會高估嚴重程度)有:身形健壯、嗜吃大量的肉者。
肌酸酐減少的情況(會低估嚴重程度)有:年紀大、女性、亞洲人、肌肉量減少(因病消瘦、截肢過後等)、肝臟疾病、發炎反應、素食者
由此可知,單用肌酸酐高或低,或者腎絲球過濾速率的多與少,是沒辦法精準判斷腎臟實際狀況的。
再來,關於症狀,有哪些尿毒會引起的症狀需要注意呢?
症狀有:疲倦、神志混亂、吃不下、想吐、味覺嗅覺改變、抽筋、不寧腿、睡眠障礙、身體癢。
徵象有:癲癇發作、月經失調、身體體溫下降、身體肌肉減少、代謝速率增加、肋膜積水或心包膜積水、嗜睡、打嗝、血小板失能等等
身體都會努力適應這些毒素的累積所造成之症狀,然而,每個人的適應力不一樣,所以會有“明明抽血報告的毒素已經很高了,卻完全沒有症狀”,或者“報告毒素其實不大高,卻已經吐的很厲害,或很喘不舒服”,這些看似矛盾的狀況,正是在告訴我們,不可以單用抽血報告來判斷該開始洗腎與否,應該用症狀來判斷。
在一項大型研究 (The Initiating Dialysis Early and Late (IDEAL) study)有了以下幾個結論:
- 單靠腎功能指標來決定是否開始洗腎,無法使死亡率下降。
- 肌酸酐結果常常會誤判真正的腎臟衰竭程度。
- 沒有症狀的患者,若只看肌酸酐或者腎絲球過濾速率的數值,是不能夠當做開始洗腎的理由。
- 反過來說,當患者的身體無法容納多餘的液體,或者出現危險的高血鉀時,不能因為腎功能數據看起來還好,就拒絕開始洗腎。
綜合上面所述,應該將重點放在:如何讓患者在一有症狀出現時,能夠安全、平安地過渡到開始洗腎,畢竟洗腎前需要先安排一些前置準備作業。
由上一篇的討論內容可知,照顧末期腎臟病患者很重要的一環,就是充分的討論各種選項,可能面對的關卡與危險,以及做好相對應的準備,如先準備好血液透析的血管通路,或腹膜透析的管路置入等等,讓患者或照顧者,隨時觀察身體所出現的危險症狀與徵象(前面有表格),當一有症狀出現時,能夠馬上開始接受洗腎治療。
結論是,何時開始透析治療,需要個別判斷,醫病雙方都需要良好的溝通,才能獲得最適時的照顧與處理。決定開始透析的時機,更像是一門藝術(art of medicine)。
2015 KDOQI 血液透析治療指引,大綱
2015 KDOQI 血液透析治療指引討論,1.1
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National Kidney Foundation. KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am. J. Kidney Dis. 66, 884–930 (2015).