老年慢性肾脏病患者衰弱现状及康复策略
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摘要
随着全球人口老龄化的不断加剧,慢性肾脏病患病率也越来越高,已成为目前较为突出的公共健康问题之一。与普通老年人相比,患有慢性肾脏病的老年人更容易发生衰弱,出现行走障碍、功能受限,甚至严重失能。由此可见,衰弱会增加老年慢性肾脏病患者的住院率和死亡风险,降低患者的生活质量,是肾病科及老年科医生必须重视的临床问题。鉴于衰弱与老年慢性肾脏病患者不良预后的关系密切,仅对患者进行传统意义上的专科治疗远远不够,应当着力于转变治疗方式和管理模式,注重患者整体机能的康复,制定以患者为中心的个体化疾病管理方案,防止患者病情进展及发生跌倒、失能等,最大限度地提高患者的生活质量。本文通过综述老年慢性肾脏病患者发生衰弱的机制及衰弱的管理,发现应从整体评估、制定护理计划、制定营养方案及制定个体化运动方案等方面进行衰弱的管理。
With the increasingly aging of population worldwide,the prevalence of chronic kidney disease(CKD) is also increasing,and CKD has become a major threat to public health.Compared with the general elderly population,those diagnosed with CKD are more susceptible to weakness,walking impairment,functional limitations,or even severe disabilities.Therefore,weakness is associated with increased hospitalization rate and mortality risk,as well as poorer quality of life in elderly patients with CKD,which needs attention of both nephrologists and geriatrists.As there is a strong correlation between weakness and poor prognosis in elderly patients with CKD,conventional specialized treatment alone is far from enough.Instead,it is important to transform treatment modalities and management modes,focus on holistic functional rehabilitation,develop patient-centered and individualized weakness management regimen,prevent disease progression,reduce fall,disability and other risks,and maximize patient quality of life.This article reviews the mechanism of weakness and its management in elderly patients with CKD,and identifies several critical aspects of weakness management,including overall evaluation,development of nursing plan,development of nutritional regimen,and development of individualized exercise program.
With the increasingly aging of population worldwide,the prevalence of chronic kidney disease(CKD) is also increasing,and CKD has become a major threat to public health.Compared with the general elderly population,those diagnosed with CKD are more susceptible to weakness,walking impairment,functional limitations,or even severe disabilities.Therefore,weakness is associated with increased hospitalization rate and mortality risk,as well as poorer quality of life in elderly patients with CKD,which needs attention of both nephrologists and geriatrists.As there is a strong correlation between weakness and poor prognosis in elderly patients with CKD,conventional specialized treatment alone is far from enough.Instead,it is important to transform treatment modalities and management modes,focus on holistic functional rehabilitation,develop patient-centered and individualized weakness management regimen,prevent disease progression,reduce fall,disability and other risks,and maximize patient quality of life.This article reviews the mechanism of weakness and its management in elderly patients with CKD,and identifies several critical aspects of weakness management,including overall evaluation,development of nursing plan,development of nutritional regimen,and development of individualized exercise program.
引文
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[13] ROCKWOOD K,SONG XW,MACKNIGHT C,et al. A global clinical measure of fitness and frailty in elderly people[J]. Can Med Assoc J,2005,173(5):489-495.DOI:10.1503/cmaj.050051.
[14] ALFAADHEL TA,SOROKA SD,KIBERD BA,et al.Frailty and mortality in dialysis:evaluation of a clinical frailty scale[J]. Clin J Am Soc Nephrol,2015,10(5):832-840.DOI:10.2215/CJN.07760814.
[15] IYASERE OU,BROWN EA,JOHANSSON L,et al.Quality of life and physical function in older patients on dialysis:a comparison of assisted peritoneal dialysis with hemodialysis[J]. Clin J Am Soc Nephrol,2016,11(3):423-430.DOI:10.2215/CJN.01050115.
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[17] CHRISTINE C,JEFFREY P,CLAUDIA D,et al.Association between oral nutritional supplementation and clinical outcomes among patients with ESRD[J]. Clin J Am Soc Nephrol,2013,8(1):100-107. DOI:10. 2215/CJN.13091211.
[18] KURELLA TAMURA M,COVINSKY KE,CHERTOW GM,et al. Functional status of elderly adults before and after initiation of dialysis[J]. N Engl J Med,2009,361(16):1539-1547.DOI:10.1056/NEJMoa0904655.
[19] VAN LOON I,HAMAKER ME,BOEREBOOM FTJ,et al.A closer look at the trajectory of physical functioning in chronic hemodialysis[J]. Age Ageing,2017,46(6):594-599.DOI:10.1093/ageing/afx006.
[20] JOHN SG,SIGRIST MK,TAAL MW,et al.Natural history of skeletal muscle mass changes in chronic kidney disease stage 4 and 5 patients:an observational study[J].PLoS One,2013,8(5):e65372.DOI:10.1371/journal.pone.0065372.
[21] JOHANSEN KL,DALRYMPLE LS,DELGADO C,et al.Factors associated with frailty and its trajectory among patients on hemodialysis[J]. Clin J Am Soc Nephrol,2017,12(7):1100-1108.DOI:10.2215/CJN.12131116.
[22] KONSTANTINIDOU E,KOUKOUVOU G,KOUIDI E,et al.Exercise training in patients with end-stage renal disease on hemodialysis:comparison of three rehabilitation programs[J]. J Rehabil Med,2002,34(1):40-45. DOI:10.1080/165019702317242695.
[23] INTISO D.The rehabilitation role in chronic kidney and end stage renal disease[J]. Kidney Blood Press Res,2014,39(2-3):180-188.DOI:10.1159/000355795.
[24]王欣欣,马迎春.慢性肾脏病康复治疗的研究进展[J].临床内科杂志,2015,32(12):860-861.DOI:10.3969/j.issn.1001-9057.2015.12.030.
[25] HEIWE S,JACOBSON SH.Exercise training for adults with chronic kidney disease[J].Cochrane Database Syst Rev,2011,5(10):CD003236. DOI:10.1002/14651858.CD003236.pub2.
[26] GREENWOOD SA,LINDUP H,TAYLOR K,et al.Evaluation of a pragmatic exercise rehabilitation programme in chronic kidney disease[J]. Nephrol Dial Transplant,2012,27(S3):126-134.DOI:10.1093/ndt/gfs272.
[27] TENTORI F,ELDER SJ,THUMMA J,et al.Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study(DOPPS):correlates and associated outcomes[J]. Nephrol Dial Transplant,2010,25(9):3050-3062.DOI:10.1093/ndt/gfq138.
[28] FARRAGHER J,JASSAL SV.Rehabilitation of the geriatric dialysis patient[J].Semin Dial,2012; 25(6):649-656.DOI:10.1111/sdi.12014.
[2] BOWLING CB,SAWYER P,CAMPBELL RC,et al.Impact of chronic kidney disease on activities of daily living in community-dwelling older adults[J].J Gerontol A Biol Sci Med Sci,2011,66(6):689-694.DOI:10.1093/gerona/glr043.
[3] MCADAMS-DEMARCO MA,SURESH S,LAW A,et al.Frailty and falls among adult patients undergoing chronic hemodialysis:a prospective cohort study[J]. BMC Nephrol,2013,14:224.DOI:10.1186/1471-2369-14-224.
[4] BAO Y,DALRYMPLE L,CHERTOW GM,et al. Frailty,dialysis initiation,and mortality in end-stage renal disease[J]. Arch Intern Med,2012,172(14):1071-1077. DOI:10.1001/archinternmed.2012.3020.
[5] MCADAMS-DEMARCO MA,LAW A,SALTER ML,et al.Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis[J].J Am Geriatr Soc,2013,61(6):896-901. DOI:10.1111/jgs.12266.
[6] WOLFE RR,MILLER SL,MILLER KB.Optimal protein intake in the elderly[J]. Clin Nutr,2008,27(5):675-684.DOI:10.1016/j.clnu.2008.06.008.
[7] GORDON PL,DOYLE JW,JOHANSEN KL.Association of 1,25-dihydroxyvitamin D levels with physical performance and thigh muscle cross-sectional area in chronic kidney disease stage 3 and 4[J].J Ren Nutr,2012,22(4):423-433.DOI:10.1053/j.jrn.2011.10.006.
[8] KOOMAN JP,KOTANKO P,SCHOLS AM,et al.Chronic kidney disease and premature ageing[J].Nat Rev Nephrol,2014,10(12):732-742.DOI:10.1038/nrneph.2014.185.
[9] KOOMAN JP,BROERS NJH,USVYAT L,et al.Out of control:accelerated aging in uremia[J]. Nephrol Dial Transplant,2013,28(1):48-54. DOI:10. 1093/ndt/gfs451.
[10] ROSHANRAVAN B,KHATRI M,ROBINSON-COHEN C,et al.A prospective study of frailty in nephrology-referred patients with CKD[J].Am J Kidney Dis,2012,60(6):912-921.DOI:10.1053/j.ajkd.2012.05.017.
[11] HUBBARD RE,PEEL NM,SMITH M,et al.Feasibility and construct validity of a frailty index for patients with chronic kidney disease[J].Australas J Ageing,2015,34(3):E9-12.DOI:10.1111/ajag.12231.
[12] ROCKWOOD K,ANDREW M,MITNITSKI A. A comparison of two approaches to measuring frailty in elderly people[J].J Gerontol A Biol Sci Med Sci,2007,62(7):738-743.
[13] ROCKWOOD K,SONG XW,MACKNIGHT C,et al. A global clinical measure of fitness and frailty in elderly people[J]. Can Med Assoc J,2005,173(5):489-495.DOI:10.1503/cmaj.050051.
[14] ALFAADHEL TA,SOROKA SD,KIBERD BA,et al.Frailty and mortality in dialysis:evaluation of a clinical frailty scale[J]. Clin J Am Soc Nephrol,2015,10(5):832-840.DOI:10.2215/CJN.07760814.
[15] IYASERE OU,BROWN EA,JOHANSSON L,et al.Quality of life and physical function in older patients on dialysis:a comparison of assisted peritoneal dialysis with hemodialysis[J]. Clin J Am Soc Nephrol,2016,11(3):423-430.DOI:10.2215/CJN.01050115.
[16] MILNE AC,POTTER J,VIVANTI A.Protein and energy supplementation in elderly people at risk from malnutrition[J]. Cochrane Database Syst Rev,2002(3):CD003288.DOI:10.1002/14651858.CD003288.
[17] CHRISTINE C,JEFFREY P,CLAUDIA D,et al.Association between oral nutritional supplementation and clinical outcomes among patients with ESRD[J]. Clin J Am Soc Nephrol,2013,8(1):100-107. DOI:10. 2215/CJN.13091211.
[18] KURELLA TAMURA M,COVINSKY KE,CHERTOW GM,et al. Functional status of elderly adults before and after initiation of dialysis[J]. N Engl J Med,2009,361(16):1539-1547.DOI:10.1056/NEJMoa0904655.
[19] VAN LOON I,HAMAKER ME,BOEREBOOM FTJ,et al.A closer look at the trajectory of physical functioning in chronic hemodialysis[J]. Age Ageing,2017,46(6):594-599.DOI:10.1093/ageing/afx006.
[20] JOHN SG,SIGRIST MK,TAAL MW,et al.Natural history of skeletal muscle mass changes in chronic kidney disease stage 4 and 5 patients:an observational study[J].PLoS One,2013,8(5):e65372.DOI:10.1371/journal.pone.0065372.
[21] JOHANSEN KL,DALRYMPLE LS,DELGADO C,et al.Factors associated with frailty and its trajectory among patients on hemodialysis[J]. Clin J Am Soc Nephrol,2017,12(7):1100-1108.DOI:10.2215/CJN.12131116.
[22] KONSTANTINIDOU E,KOUKOUVOU G,KOUIDI E,et al.Exercise training in patients with end-stage renal disease on hemodialysis:comparison of three rehabilitation programs[J]. J Rehabil Med,2002,34(1):40-45. DOI:10.1080/165019702317242695.
[23] INTISO D.The rehabilitation role in chronic kidney and end stage renal disease[J]. Kidney Blood Press Res,2014,39(2-3):180-188.DOI:10.1159/000355795.
[24]王欣欣,马迎春.慢性肾脏病康复治疗的研究进展[J].临床内科杂志,2015,32(12):860-861.DOI:10.3969/j.issn.1001-9057.2015.12.030.
[25] HEIWE S,JACOBSON SH.Exercise training for adults with chronic kidney disease[J].Cochrane Database Syst Rev,2011,5(10):CD003236. DOI:10.1002/14651858.CD003236.pub2.
[26] GREENWOOD SA,LINDUP H,TAYLOR K,et al.Evaluation of a pragmatic exercise rehabilitation programme in chronic kidney disease[J]. Nephrol Dial Transplant,2012,27(S3):126-134.DOI:10.1093/ndt/gfs272.
[27] TENTORI F,ELDER SJ,THUMMA J,et al.Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study(DOPPS):correlates and associated outcomes[J]. Nephrol Dial Transplant,2010,25(9):3050-3062.DOI:10.1093/ndt/gfq138.
[28] FARRAGHER J,JASSAL SV.Rehabilitation of the geriatric dialysis patient[J].Semin Dial,2012; 25(6):649-656.DOI:10.1111/sdi.12014.