Assessment and risk factors analysis for quality of life in elderly patients with chronic kidney disease

发布时间：2024-12-18 02:32

开启QoS（Quality of Service）优化网络带宽分配 #生活技巧# #数码产品使用技巧# #无线网络优化#

随着“银发浪潮”的到来，老年综合征（跌倒、营养不良、肌少症、多病共存、多重用药等）的发病率直线上升，影响了老年患者的日常生活活动（activity of daily living，ADL），最终发展为衰弱[1-2]。衰弱不仅可使老年人面对应激时脆性增加、发生失能、功能下降、住院和死亡风险增加，还可导致老年人对长期照护的需求和医疗费用增加，如能早期识别并给予相应处理，可减少上述情况发生[3]。ADL能力评估有利于及早发现衰弱状态以避免进一步的严重情况。ADL包括基本日常生活活动（basic activities of daily living，BADL）和工具性日常生活活动（instrumental activities of daily living，IADL）。有研究表明，慢性肾脏病（chronic kidney disease，CKD）是老年人认知障碍和衰弱的危险因素[4]。本研究对老年CKD患者进行ADL评估并分析导致其能力下降相关的主要危险因素，以期在早期识别和筛查衰弱人群，并提出相关干预措施以提高老年CKD患者的生活质量。

对象和方法

一、研究对象

入选2016年10月至2019年10月在山西省人民医院住院的年龄≥65岁的CKD患者。纳入标准：（1）民族为汉族；（2）具有一定理解能力和语言表达能力，能配合完成本研究者。排除标准：（1）帕金森病、认知功能损害及抑郁患者；（2）恶性肿瘤及长期营养不良患者；（3）3个月内发生急性肾损伤及肾移植患者；（4）服用影响血肌酐的药物；（5）泌尿系统结石、感染；（6）急、慢性传染性疾病；（7）免疫性疾病。本研究获得山西省人民医院伦理委员会审批[伦理审批号：（2020）省医科伦审字138号]。

二、研究方法

1. 实验分组：依据是否透析分为透析组和非透析组。

2. 资料收集：收集患者血肌酐、尿素氮、空腹血糖、血尿酸（serum uric acid，SUA）、总胆固醇、三酰甘油、高密度脂蛋白胆固醇（high-density lipoprotein cholesterol，HDL-C）、低密度脂蛋白胆固醇（low-density lipoprotein cholesterol，LDL-C）、电解质（血钾、血钠、血氯）和血红蛋白等基线资料。

3. 简明老年综合评估（comprehensive geriatric assessment，CGA）评分：简明CGA量表包括BADL功能评定量表、IADL功能评估量表和改良老年疾病累计评分表（MCIRS-G）（合并症评估）。（1）BADL功能评定量表：以Barthel指数（BI）作为评估工具对ADL进行评估，由10个项目组成，包括进食、穿衣、转移、修饰、洗澡、大便、小便、如厕、活动和上下楼梯。满分为100分，<20分为极严重功能缺陷，生活完全需要依赖；20分≤评分<40分为生活需要极大帮助；40分≤评分<60分为生活需要帮助；≥60分为生活基本自理。（2）IADL功能评估量表：从上街购物、外出活动、家务维持、使用电话能力、服用药物、处理财务能力等方面进行评分，满分为24分，分值越低，依赖性越强。（3）MCIRS-G：对心脏、高血压、血管（含血液系统）、呼吸系统、眼耳鼻喉咽、上消化道、下消化道、肝脏、肾脏、泌尿系统、肌肉骨髓系统、神经系统、内分泌代谢、精神心理等14个系统进行评分。每个系统疾病的严重程度均分为5级（分别记1~5分）：没有伤害（1分）；轻微损害，但不干扰正常活动，无需治疗，预后良好（2分）；中度损害，干扰正常活动，需要治疗，预后良好（3分）；重度损害，可能致残，需要立即治疗，预后较差（4分）；致命性损害，紧急需要治疗，预后严重（5分）。总分是将各项的分数累加得出，若同一系统同时出现一个以上疾病时，只需记录最严重的的疾病。

4. CKD的定义和诊断标准：依据2012年改善全球肾脏病预后组织（KDIGO）定义的CKD诊断标准进行诊断[5]。

5. 估算肾小球滤过率（estimated glomerular filtration rate，eGFR）的计算：按照简化肾病饮食改良方程公式计算eGFR，eGFR=186×血清肌酐（mg/dl）-1.154×年龄（岁）-0.203×性别系数（男性=1，女性=0.742）。

三、统计学方法

采用SPSS 23.0软件进行数据处理。符合正态分布的计量资料用x ± s表示，两组间比较使用独立样本t检验。采用Pearson相关分析分析不同量表评分与各个临床指标之间的相关关系，进一步使用多元线性回归分析老年CKD患者生活质量的相关影响因素。P<0.05视为差异具有统计学意义。

结果

1. 一般资料：本研究纳入年龄≥65岁的CKD患者共189例，基线资料描述见

表1

。

表1 慢性肾脏病患者基线资料（± s） 项目数值例数年龄(岁) 76.746±7.863 189 eGFR[ml·min-1·(1.73 m2)-1] 22.473±17.933 189 收缩压(mmHg) 149.185±26.260 189 血红蛋白(g/L) 97.513±22.640 189 空腹血糖(mmol/L) 5.848±3.220 171 血尿酸(μmol/L) 407.452±165.451 189 总胆固醇(mmol/L) 4.210±1.337 186 三酰甘油(mmol/L) 1.482±0.884 186 高密度脂蛋白胆固醇(mmol/L) 1.089±0.338 186 低密度脂蛋白胆固醇(mmol/L) 2.533±0.904 186 白蛋白(g/L) 33.292±7.417 187 血钾(mmol/L) 4.409±0.698 189 血钠(mmol/L) 137.340±4.803 189 血氯(mmol/L) 105.124±6.015 189 B型钠尿肽(ng/L) 1 176.884±3 050.472 156 BADL评分(分) 82.248±27.721 189 IADL评分(分) 13.011±7.122 189 MCIRS-G评分(分) 29.122±5.019 189 除肾脏因素外的MCIRS-G评分(分) 24.487±4.737 189注：eGFR：估算肾小球滤过率；BADL：基本日常生活活动；IADL：工具性日常生活活动；MCIRS-G：改良老年疾病累计评分表；1 mmHg=0.133 kPa

2. 男性和女性CKD患者间的CGA评分比较：男性CKD患者BADL和IADL评分均高于女性（t=-4.247，P<0.001；t=-3.076，P=0.002）。为排除肾脏疾病因素干扰，比较了除肾脏因素外的MCIRS-G评分，两组间差异无统计学意义（t=1.038，P=0.301）。见

表2

。

表2 慢性肾脏病患者男性和女性的老年综合评估评分比较（± s） 项目女性(n=74) 男性(n=115) t值 P值 BADL评分(分) 72.03±33.11 88.83±21.30 -4.247 <0.001 IADL评分(分) 11.07±7.47 14.16±6.63 -3.076 0.002 除肾脏因素外的MCIRS-G评分(分) 24.93±4.79 24.20±4.70 1.038 0.301注：BADL：基本日常生活活动；IADL：工具性日常生活活动；MCIRS-G：改良老年疾病累计评分表

3. 透析组和非透析组的CGA评分比较：透析组90例，非透析组99例。透析组患者的BADL评分和IADL评分显著均低于非透析组[（70.00±33.28）分比（93.38±14.32）分，t=6.166，P<0.001；（9.78±7.12）分比（15.95±5.74）分，t=6.520，P<0.001]。无论是否包含肾脏评分，透析组MCIRS-G评分均显著高于非透析组[（31.13±4.00）分比（27.29±5.17）分，t=-5.741，P<0.001；（26.06±4.12）分比（23.06±4.83）分，t=-4.598，P<0.001]。见

表3

。

表3 透析组和非透析组的老年综合评估评分比较（± s） 项目非透析组(n=99) 透析组(n=90) t值 P值 BADL评分(分) 93.38±14.32 70.00±33.28 6.166 <0.001 IADL评分(分) 15.95±5.74 9.78±7.12 6.520 <0.001 MCIRS-G评分(分) 27.29±5.17 31.13±4.00 -5.741 <0.001 除肾脏因素外的MCIRS-G评分(分) 23.06±4.83 26.06±4.12 -4.598 <0.001注：BADL：基本日常生活活动；IADL：工具性日常生活活动；MCIRS-G：改良老年疾病累计评分表

4. 不同量表评分与各个临床指标的线性相关分析：因透析对患者检验指标有影响，所以选择非透析组患者数据行线性回归分析。结果显示，与BADL评分呈正相关的因素为eGFR、SUA、LDL-C、HDL-C、血钾和血氯（均P<0.05），呈负相关的因素为BNP（P<0.01）；与IADL评分呈正相关的因素为eGFR、SUA、HDL-C、LDL-C、血钾和血氯（均P<0.05），呈负相关的因素为年龄和BNP（均P<0.05）；无论是否包含肾脏评分，空腹血糖均与MCIRS-G评分呈正相关，eGFR、SUA、总胆固醇和HDL-C与MCIRS-G评分呈负相关（均P<0.05）。见

表4

。

表4 不同量表评分与各个临床指标的线性相关性（Pearson相关分析，n=99） 指标 BADL评分 IADL评分 MCIRS-G评分除肾脏因素外的MCIRS-G评分 r值 P值 r值 P值 r值 P值 r值 P值年龄(岁) -0.130 0.075 -0.296 <0.001 0.074 0.309 0.099 0.174 eGFR
0.370 <0.001 0.464 <0.001 -0.446 <0.001 -0.313 <0.001 收缩压(mmHg) 0.052 0.189 -0.050 0.189 0.128 0.079 0.118 0.105 舒张压(mmHg) 0.062 0.397 0.051 0.482 -0.077 0.290 -0.061 0.407 血红蛋白(g/L) -0.080 0.297 -0.103 0.181 0.044 0.569 0.057 0.462 空腹血糖(mmol/L) -0.098 0.178 0.047 0.519 0.171 0.019 0.172 0.018 血尿酸(μmol/L) 0.215 0.003 0.235 0.001 -0.211 0.004 -0.209 0.004 总胆固醇(mmol/L) 0.121 0.099 0.138 0.060 -0.165 0.024 -0.145 0.048 三酰甘油(mmol/L) 0.110 0.135 0.086 0.245 -0.113 0.126 -0.133 0.070 HDL-C(mmol/L) 0.204 0.005 0.234 0.001 -0.193 0.008 -0.188 0.010 LDL-C(mmol/L) 0.152 0.038 0.197 0.007 -0.023 0.751 -0.013 0.856 白蛋白(g/L) -0.046 0.527 -0.077 0.289 0.148 0.052 0.134 0.066 血钾(mmol/L) 0.180 0.013 0.280 <0.001 -0.092 0.210 -0.084 0.252 血氯(mmol/L) 0.167 0.021 0.198 0.006 -0.081 0.266 -0.079 0.278 BNP(ng/L) -0.262 0.001 -0.189 0.018 0.134 0.094 0.129 0.107注：BADL：基本日常生活活动；IADL：工具性日常生活活动；MCIRS-G：改良老年疾病累计评分表；eGFR：估算肾小球滤过率，单位为ml·min-1·(1.73 m2)-1；HDL-C：高密度脂蛋白胆固醇；LDL-C：低密度脂蛋白胆固醇；BNP：B型钠尿肽；1 mmHg=0.133 kPa

5. BADL评分的相关影响因素：采用多元线性回归对BADL评分进行单因素分析，结果显示，BADL的独立影响因素为eGFR（t=3.231，P=0.002），见

表5

。

表5 基本日常生活活动量表评分的相关影响因素（多元线性回归分析，n=99） 指标未标准化系数标准化系数β t值 P值 B 标准误差常量 11.939 42.276 0.282 0.778 eGFR[ml·min-1·(1.73 m2)-1] 0.466 0.144 0.272 3.231 0.002 红细胞(×1012/L) 3.377 3.283 0.086 1.029 0.305 血小板(×109/L) 0.049 0.031 0.126 1.540 0.126 血尿酸(μmol/L) -0.023 0.013 -0.139 -1.766 0.079 HDL-C(mmol/L) 0.190 7.004 0.002 0.027 0.978 LDL-C(mmol/L) 1.646 2.720 0.054 0.605 0.546 血钾(mmol/L) 2.200 3.142 0.056 0.700 0.485 血氯(mmol/L) 0.344 0.360 0.074 0.956 0.341注：eGFR：估算肾小球滤过率；HDL-C：高密度脂蛋白胆固醇；LDL-C：低密度脂蛋白胆固醇

6. IADL评分的相关影响因素：多元线性回归分析结果显示，IADL评分的独立影响因素为年龄（t=-2.395，P=0.018）和eGFR（t=4.302，P<0.001），见

表6

。

表6 工具性日常生活活动量表评分的相关影响因素（多元线性回归分析，n=99） 指标未标准化系数标准化系数β t值 P值 B 标准误差常量 2.357 10.943 0.215 0.830 年龄(岁) -0.158 0.066 -0.176 -2.395 0.018 eGFR[ml·min-1·(1.73 m2)-1]
0.143 0.033 0.344 4.302 <0.001 红细胞(×1012/L) 0.521 0.770 0.055 0.677 0.500 血小板(×109/L) 0.011 0.007 0.116 1.477 0.142 血尿酸(μmol/L) 0.001 0.003 0.036 0.481 0.631 HDL-C(mmol/L) 0.248 1.649 0.012 0.150 0.881 LDL-C(mmol/L) 0.401 0.646 0.055 0.621 0.535 血氯(mmol/L) 0.130 0.084 0.116 1.539 0.126注：eGFR：估算肾小球滤过率；HDL-C：高密度脂蛋白胆固醇；LDL-C：低密度脂蛋白胆固醇

讨论

衰老是CKD的主要危险因素之一，而CKD老年患者衰弱的发生率（高达60％）是健康老年人的6倍[6]。本研究拟探讨老年CKD患者生活质量的相关影响因素。结果显示，老年CKD患者男性BADL评分及IADL评分均显著高于女性，考虑为男性体重指数、肌肉力量、平衡能力和活动能力等方面均强于女性的缘故。而除肾脏因素外的MCIRS-G评分男女组间差异无统计学意义。肾脏为多种疾病的靶器官，CKD患者的特点是多病共存[7]。与非透析组相比，透析组患者BADL评分及IADL评分均显著降低，而MCIRS-G评分显著升高；这与Falsetti等[8]和Talib等[9]的研究相符，合并症指数越高，老年CKD患者的功能下降越多，进展为终末期肾病的风险越高；同时有研究显示，老年终末期肾病患者过早开始透析治疗并未明显获益，且部分老年人在透析后容易出现衰弱、跌倒、认知障碍以及焦虑、抑郁等心理、精神疾患[10]。这与本研究结果一致，透析组患者生活质量明显下降，进一步影响了老年人的心理健康和社会适应能力，另外还将给家庭和社会带来沉重的负担。对老年CKD患者的生活质量及其影响因素的研究有助于早期发现危险人群并早期干预，以改善老年人的生存质量。同时建议老年CKD患者开始透析治疗前应首先进行综合评估，以决定患者是否适合透析治疗[11]。

本研究分析了患者生活质量的影响因素，研究中发现与BADL及IADL评分呈正相关的因素为eGFR、SUA、HDL-C、LDL-C、血钾和血氯，与BADL评分呈负相关的因素为BNP，与IADL评分呈负相关的因素为年龄和BNP；与MCIRS-G评分呈正相关的因素为空腹血糖，呈负相关的因素为总胆固醇、HDL-C、eGFR和SUA；其中生活质量的独立影响因素为eGFR。这与许多的研究结果一致[12⇓-14]，Ozturk和Toprak[15]的结果提示eGFR和生活质量评分之间存在显著相关性。当eGFR降低时，生活质量评分降低，日常生活依赖性越强。本研究表明，年龄与BADL评分呈负相关，年龄与日常生活能力密切相关。因此，随着年龄的增长，日常生活能力评估应引起更多关注[16⇓-18]。其中有争议的为SUA与生活质量的关系，目前的研究多表示基础SUA水平不能预测肾功能，且与CKD患者心血管死亡率之间的关系不确定[19⇓-21]。但可以肯定的是，SUA升高是CKD患者心血管疾病死亡风险增加的预测因素，且SUA升高是肾功能下降的独立危险因素[19,22-23]。

本研究存在一些不足。首先，这是三级医院的单中心研究，可能存在样本的局限性，有些危险因素未能得出阳性结果。其次，本研究未将多重用药、认知障碍、社会因素、康复锻炼等因素纳入分析，这些也可能与患者的日常生活能力下降有关。在入院时行规范老年综合评估，在给予规范诊疗、营养干预、康复指导后增加随访，以明确患者的预后，这是我们接下来研究的方向。

综上所述，老年CKD患者更容易出现日常生活能力下降。BADL量表和IADL量表，尤其是IADL状况可以更早期识别衰弱情况并评估晚期CKD患者的功能适应性。为提高老年CKD患者生活质量，应积极进行老年综合评估，以便早期识别衰弱同时进行合并症的综合管理，以维持eGFR水平。

=2" class="main_content_center_left_zhengwen_bao_erji_title main_content_center_left_one_title" style="font-size: 16px;">{{custom_sec.title}}{{custom_sec.content}}[1]Gołębiowski T

Augustyniak-Bartosik H

Weyde W

, et al. Geriatric syndromes in patients with chronic kidney disease[J]. Postepy Hig Med Dosw (Online), 2016, 70(0): 581-589. DOI: 10.5604/17322693.1204562.

The recent epidemiologic data pointed out, that the general number of patients on hemodialysis is steadily increasing, especially in group of elderly patients over 75 years old. The geriatric syndromes are a multietiological disorder related to physiological aging and partly associated with comorbid conditions. Frailty, falls, functional decline and disability, cognitive impairment and depression are main geriatric syndromes and occurs in patients with impaired renal function more often than among general population. The causes of higher prevalence of those syndromes are not well known, but uremic environment and overall renal replacement therapy may have an important impact on its progress. The patient with geriatric syndrome require comprehensive treatment as well as physical rehabilitation, psychiatric cure and support in everyday activities. Herein below we would like to review recent literature regarding to particular features of main geriatric syndromes in a group of nephrological patients.

Bampouras TM

Pendleton N

, et al. Diagnostic accuracy of frailty screening methods in advanced chronic kidney disease[J]. Nephron, 2019, 141(3): 147-155. DOI: 10.1159/000494223.

Background/Aims: Frail patients with chronic kidney disease (CKD) have an increased hospitalisation and mortality rate. However, many popular frailty screening methods have not been validated in patients with CKD. This study evaluates the diagnostic accuracy of several frailty screening methods in patients with CKD G4–5 and those established on haemodialysis (G5D). Methods: Ninety participants with CKD G4–5D were recruited from Nephrology Outpatient Clinics and 2 Haemodialysis Units between December 2016 and December 2017. Frailty was diagnosed using the Fried Frailty Phenotype. The following frailty screening tests were evaluated: Clinical Frailty Scale, PRISMA-7, CKD Frailty Index, CKD FI-LAB, walking speed, hand grip strength and Short Physical Performance Battery. Results: The mean age of participants was 69 years (SD ±13). One-third of participants were dialysis-dependent. Nineteen (21%) patients were categorised as frail, 42 (47%) as pre-frail and 29 (32%) as robust. Overall, walking speed was the most discriminative measure (AUC 0.97 [95% CI 0.93–1.00], sensitivity 0.84 [95% CI 0.62–0.94], specificity 0.96 [95% CI 0.88–0.99]). The Clinical Frailty Scale had the best performance of the non-physical assessment frailty screening methods (AUC 0.90 [95% CI 0.84–0.97], sensitivity 0.79 [95% CI 0.57–0.91], specificity 0.87 [95% CI 0.78–0.93]). Conclusions: Walking speed can be used to accurately screen for frailty in CKD populations. If it is not practical to perform a physical assessment to screen for frailty, the Clinical Frailty Scale is a useful alternative.

{{custom_citation.content}}https://doi.org/{{custom_citation.doi}}https://www.ncbi.nlm.nih.gov/pubmed/{{custom_citation.pmid}}{{custom_citation.url}}本文引用 [{{custom_ref.citedCount}}]摘要{{custom_citation.annotation}}[3]{{custom_citation.content}}https://doi.org/{{custom_citation.doi}}https://www.ncbi.nlm.nih.gov/pubmed/{{custom_citation.pmid}}{{custom_citation.url}}本文引用 [{{custom_ref.citedCount}}]摘要{{custom_citation.annotation}}[4]Shen Z

Ruan Q

Yu Z

, et al. Chronic kidney disease-related physical frailty and cognitive impairment: a systemic review[J]. Geriatr Gerontol Int, 2017, 17(4): 529-544. DOI: 10.1111/ggi.12758.

The objective of this review was to assess chronic kidney disease-related frailty and cognitive impairment, as well as their probable causes, mechanisms and the interventions.Studies from 1990 to 2015 were reviewed to evaluate the relationship between chronic kidney disease and physical frailty and cognitive impairment. Of the 1694 studies from the initial search, longitudinal studies (n = 22) with the keywords "Cognitive and CKD" and longitudinal or cross-sectional studies (n = 5) with the keywords "Frailty and CKD" were included in final analysis.By pooling current research, we show clear evidence for a relationship between chronic kidney disease and frailty and cognitive impairment in major studies. Vascular disease is likely an important mediator, particularly for cognitive impairment. However, non-vascular factors also play an important role. Many of the other mechanisms that contribute to impaired cognitive function and increased frailty in CKD remain to be elucidated. In limited studies, medication therapy did not obtain the ideal effect. There are limited data on treatment strategies, but addressing the vascular disease risk factors earlier in life might decrease the subsequent burden of frailty and cognitive impairment in this population. Multidimensional interventions, which address both microvascular health and other factors, may have substantial benefits for both the cognitive impairments and physical frailty in this vulnerable population.Chronic kidney disease is a potential cause of frailty and cognitive impairment. Vascular and non-vascular factors are the possible causes. The mechanism of chronic kidney disease-induced physical frailty and cognitive impairment suggests that multidimensional interventions may be effective therapeutic strategies in the early stage of chronic kidney disease. Geriatr Gerontol Int 2017; 17: 529-544.© 2016 Japan Geriatrics Society.

. Comments on 'KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease'[J]. Kidney Int, 2013, 84(3): 622-623. DOI: 10.1038/ki.2013.243.

Bampouras TM

Pendleton N

, et al. Frailty and chronic kidney disease: current evidence and continuing uncertainties[J]. Clin Kidney J, 2018, 11(2): 236-245. DOI: 10.1093/ckj/sfx134.

Frailty, the state of increased vulnerability to physical stressors as a result of progressive and sustained degeneration in multiple physiological systems, is common in those with chronic kidney disease (CKD). In fact, the prevalence of frailty in the older adult population is reported to be 11%, whereas the prevalence of frailty has been reported to be greater than 60% in dialysis-dependent CKD patients. Frailty is independently linked with adverse clinical outcomes in all stages of CKD and has been repeatedly shown to be associated with an increased risk of mortality and hospitalization. In recent years there have been efforts to create an operationalized definition of frailty to aid its diagnosis and to categorize its severity. Two principal concepts are described, namely the Fried Phenotype Model of Physical Frailty and the Cumulative Deficit Model of Frailty. There is no agreement on which frailty assessment approach is superior, therefore, for the time being, emphasis should be placed on any efforts to identify frailty. Recognizing frailty should prompt a holistic assessment of the patient to address risk factors that may exacerbate its progression and to ensure that the patient has appropriate psychological and social support. Adequate nutritional intake is essential and individualized exercise programmes should be offered. The acknowledgement of frailty should prompt discussions that explore the future care wishes of these vulnerable patients. With further study, nephrologists may be able to use frailty assessments to inform discussions with patients about the initiation of renal replacement therapy.

Levin A

Manns BJ

, et al. Effective CKD care in European countries: challenges and opportunities for health policy[J]. Am J Kidney Dis, 2015, 65(1): 15-25. DOI: 10.1053/j.ajkd.2014.07.033.

Chronic kidney disease (CKD) is an important global public health problem that is associated with adverse health outcomes and high health care costs. Effective and cost-effective treatments are available for slowing the progression of CKD and preventing its complications, including cardiovascular disease. Although wealthy nations have highly structured schemes in place to support the care of people with kidney failure, less consideration has been given to health systems and policy for the much larger population of people with non-dialysis-dependent CKD. Further, how to integrate such strategies with national and international initiatives for control of other chronic noncommunicable diseases (NCDs) merits attention. We synthesized the various approaches to CKD control across 17 European countries and present our findings according to the key domains suggested by the World Health Organization framework for NCD control. This report identifies opportunities to strengthen CKD-relevant health systems and explores potential mechanisms to capitalize on these opportunities. Across the 17 countries studied, we found a number of common barriers to the care of people with non-dialysis-dependent CKD: limited work force capacity, the nearly complete absence of mechanisms for disease surveillance, lack of a coordinated CKD care strategy, poor integration of CKD care with other NCD control initiatives, and low awareness of the significance of CKD. These common challenges faced by diverse health systems reflect the need for international cooperation to strengthen health systems and policies for CKD care. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Viticchi G

Tarquinio N

, et al. Charlson comorbidity index as a predictor of in-hospital death in acute ischemic stroke among very old patients: a single-cohort perspective study[J]. Neurol Sci, 2016, 37(9): 1443-1448. DOI: 10.1007/s10072-016-2602-1.

Chronic diseases are increasing worldwide. Association of two or more chronic conditions is related with poor health status and reduced life expectancy, particularly among elderly patients. Comorbidities represent a risk factor for adverse events in several critical illnesses. We aimed to evaluate if elderly patients are affected by multiple chronic pathologies, assessed by Charlson comorbidity index (CCI), showed a reduced in-hospital survival after ischemic stroke. In a 3-year period, we evaluated all the subjects admitted to our internal medicine department for ischemic stroke. Age, sex, NIHSS score and all the comorbidities were recorded. Days of hospitalization, hospital-related infections and in-hospital mortality were also assessed. For each patient, we evaluated CCI, obtaining four classes: group 1 (CCI: 2-3), group 2 (CCI: 4-5), group 3 (CCI: 6-7) and group 4 (CCI: ≥8). Survival was evaluated with Kaplan-Meier and Cox regression analyses. The complete model considered in-hospital death as the main outcome, days of hospitalization as the time variable and CCI as the main predictor, adjusting for NIHSS, sex and nosocomial infections. Patients in CCI group 3 and 4 had an increased risk of in-hospital mortality, independently of NIHSS, sex and nosocomial infections. Elderly patients with multiple comorbidities have higher risk of in-hospital death when affected by ischemic stroke.

Sharif F

Manzoor S

, et al. Charlson comorbidity index for prediction of outcome of acute kidney injury in critically Ill patients[J]. Iran J Kidney Dis, 2017, 11(2): 115-123.

This study aimed to determine predictors of outcomes in critically ill patients with acute kidney injury (AKI), and to study the impact of the Charlson Comorbidity Index (CCI) as a prognostic indicator.This retrospective study included critically ill patients who were admitted with AKI or developed AKI during their hospital stay. The impact of comorbidity was evaluated by the CCI, while severity of AKI was assessed by the RIFLE criteria.The mean age of 786 patients with AKI was 59.0 ± 17.0 years (59% men). The most common cause was sepsis in 51% of the patients. In-hospital mortality rate was 42%. The need for mechanical ventilation (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.23 to 3.04), vasoactive drugs (OR, 9.67; 95% CI, 6.35 to 14.73), dialysis (OR, 1.78; 95% CI, 1.14 to 2.78), failure class of RIFLE criteria (OR, 2.02; 95% CI, 1.00 to 4.08), and a CCI greater than 6 (OR, 2.20; 95% CI, 1.38 to 3.52) were independently associated with mortality. At 90 days of follow-up, 6% of the patients were dialysis dependent, while 32% and 62% had partial and complete recovery, respectively. In multivariable analysis, a CCI greater than 6 (OR, 0.47; 95% CI, 0.26 to 0.83), need for dialysis in hospital (OR, 0.31; 95% CI, 0.17 to 0.54), and failure class (OR, 0.19; 95% CI, 0.07 to 0.55) were independent predictors of poor renal outcomes.The CCI independently predicts in-patient mortality and poor renal outcomes in patients with AKI.

Brunori G

Dalmartello M

, et al. Assessment of the geriatric competence and perceived needs of Italian nephrologists: an internet survey[J]. J Nephrol, 2016, 29(3): 385-390. DOI: 10.1007/s40620-015-0232-y.

An internet survey was set up to assess the geriatric competence and perceived needs of 337 members of the Italian society of nephrology (SIN). The survey assessed how well aware nephrologists are of the typical geriatric conditions and needs of their elderly chronic kidney disease (CKD) patients. SIN associates were also questioned about their current use of comprehensive geriatric assessment, prescription of potentially nephrotoxic drugs, and screening for osteoporosis. The main finding is that CKD and dialysis are almost unanimously perceived as typically geriatric conditions, but knowledge and use of geriatric tools are scanty. While use of potentially inappropriate drugs is rare, almost half of the patients are not screened for osteoporosis. The significant clinical gaps observed could greatly impair the management of older CKD patients, and call for an urgent educational intervention.

Jaikaransingh V

Hedayati SS

. End-stage kidney disease in the elderly: approach to dialysis initiation, choosing modality, and predicting outcomes[J]. Adv Chronic Kidney Dis, 2016, 23(1): 36-43. DOI: 10.1053/j.ackd.2015.08.005.

Ferrer A

Pérez-Castejon JM

, et al. Risk factors for functional decline in nonagenarians: a one-year follow-up. The NonaSantfeliu study[J]. Gerontology, 2007, 53(4): 211-217. DOI: 10.1159/000100780.

Disability and a decline in functional capacity are common in old age.To determine predictors of functional decline in nonagenarians' basic activities of daily living (ADL) after 1 year of follow-up.A sample of 97 nonagenarians subjects not previously severely dependent (Barthel Index >59) was evaluated. This sample included 72 women (74.2%) and the mean (SD) age was 93.4 +/- 2.7 years. The following data were collected: sociodemographic data, Barthel Index (BI), Lawton-Brody Index (LI), Mental State Examination (MEC), a short version of the Mini-Nutritional Assessment, comorbidity (Charlson Index), lower-extremity function, Gait Rating Scale from the Tinetti Performance-Oriented Mobility Scale and prevalent chronic diseases. Subjects who had a 10-point or higher decline in the BI in 1 year were compared to subjects who had no decline or a maximum decline of 9 points. In addition, subjects whose total BI score fell below 60 were compared to the group of subjects who maintained scores between 60 and 100. The Student's t test, the chi(2) or the Fisher's exact test, and a multiple logistic regression analysis (with the identified risk factors of age and gender) were performed.39 nonagenarians experienced a 10-point or higher decline in the BI in 1 year. A lower LI score (p = 0.003) and visual impairment (p = 0.01) were associated with functional decline. The multiple regression analysis showed that there was a significant association with LI (odds ratio (OR) 0.74, confidence interval 95% 0.60-0.91, p < 0.005). The 18 nonagenarians who had a BI <60 had a BI >60 at baseline. Lower scores on the LI (p = 0.004) and on the MEC (p = 0.01), a history of a previous stroke (p = 0.009) and higher Charlson Index scores (p = 0.03) were associated with recently acquired, severe dependency. A multiple regression analysis showed a significant association between LI (OR 0.65, 0.47-0.89, p < 0.008) and a history of previous strokes (OR 3.39, 1.01-11.34, p < 0.04).According to the definition used to describe functional basic ADL decline, poor performance in instrumental ADL at baseline and a history of a stroke appear to be independent risk factors. Prevention strategies could be intensified in this subgroup of nonagenarians.Copyright 2007 S. Karger AG, Basel.

Paterna Mellinas G

Martínez Sánchez E

, et al. [Comorbidity in the elderly: utility and validity of assessment tools][J]. Rev Esp Geriatr Gerontol, 2010, 45(4): 219-228. DOI: 10.1016/j.regg.2009.10.009.

Comorbidity is common in the elderly and contributes to the complexity of this population subgroup. This problem is a risk factor for major adverse events such as functional decline, disability, dependency, poor quality-of-life, institutionalization, hospitalization and death, but is not the most important factor. Age and risk of functional decline rather than comorbidity (understood as a compilation of diseases) are the main characteristics defining the target population attended by geriatricians. Comorbidity indexes should not be interpreted independently in the elderly, but within a context of comprehensive geriatric assessment that includes age-related preclinical dysfunctions, frailty measures, and functional, mental and psychosocial issues. The clinical management of comorbidity in the elderly requires advanced knowledge of geriatrics because the treatment of one condition may worsen or lead to the development of others and because preclinical physiological dysfunctions modulate drug response. Recommending a specific comorbidity index is difficult and depends on multiple factors, due to their psychometric characteristics, applicability in the elderly and their construct. However, the Cumulative Illness Rating Scale, in the version adapted to the elderly, could be highly suitable. Other instruments, such as the Charlson index, the Index of CoExistent Disease and the Kaplan index are also valid and reproducible.Copyright © 2009 SEGG. Published by Elsevier Espana. All rights reserved.

Hoogerduijn JG

de Haan RJ

, et al. Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline[J]. PLoS One, 2011, 6(11): e26951. DOI: 10.1371/journal.pone.0026951.

Toprak D

. The relationship between glomerular filtration rate, nutrition and activities of daily living in patients with chronic kidney disease receiving homecare[J]. Prog Nutr, 2019, 21(1): 135-140. DOI: 10.23751/pn.v21i1.6704.

Introduction: The aim of this research was to evaluate the relationship among glomerular filtration rate, nutrition and activities of daily living performance in Chronic Kidney Disease patients receiving homecare services. Materials and Method: We conducted a retrospective examination of the Sisli Hamidiye Etfal Training and Research Hospital's Homecare records for 2016. 345 patients were included. Glomerular filtration ratewas calculated using a simplified version of the Modification of Diet in Renal Disease. Mini-Nutritional Assessmen scores were used for nutrition. Barthel Index scores were used to identify activities of daily living. P values of <= 0.05 were considered statistically significant. Results: 225 women (65.2%) and 120 men (34.8%), were included. Mean value of Glomerular filtration rate was 60.83 +/- 17.10 ml/min/1.73 m2. Mini-Nutritional Assessmen test mean was 19.66 +/- 4.97. Barthel Index of the study group was 30.39 +/- 28.99. A statistically significant correlation was found between glomerular filtration rateand the Barthel Index(p = 0.022). When glomerular filtration ratedecreased, Barthel Index scores decreased. As Mini-Nutritional Assessmen scores decreased, glomerular filtration rate values also decreased (p = 0.029). Barthel Index and Mini-Nutritional Assessmen were also related (p = <0.001). Conclusion: In primary care, elderly individuals (especially those receiving homecare services) should undergo assessment of activities of daily living and nutritional status. Patients with Chronic Kidney Disease were at risk for malnutrition and dependence on activities of daily living.

Zijlstra GA

Witte N

, et al. Limitations in activities of daily living in community-dwelling people aged 75 and over: a systematic literature review of risk and protective factors[J]. PLoS One, 2016, 11(10): e0165127. DOI: 10.1371/journal.pone.0165127.

Hou WW

Wang YF

, et al. Main risk factors related to activities of daily living in non-dialysis patients with chronic kidney disease stage 3-5: a case-control study[J]. Clin Interv Aging, 2020, 15: 609-618. DOI: 10.2147/CIA.S249137.

Elderly people are at increased risk of falls, disability and death due to reduced functional reserve, decline in multiple systems functions, which affects their activities of daily living (ADL) and eventually develop into frailty. The ADL assessment is conducive to early detection to avoid further serious situations. Previous studies on patients' activities of daily living with chronic kidney disease (CKD) are mainly focused on dialysis patients. Little information is available on non-dialysis patients.A total of 303 elderly patients with CKD stage 3-5 who were admitted to our hospital were selected. ADL evaluation was performed on patients at admission, with Barthel index (BI) as the evaluation tool. They were divided into two groups based on BI (≥60 and <60). Demographic information, lifestyle and clinical profile were collected. The risk factors related to ADL were analyzed by univariate and multivariate models.The data of 303 patients enrolled in this study were analyzed. The average age of patients was 84.48± 7.14 years and 62.05% were male. There were 88 patients (29.04%) in BI <60 group and 215 patients (70.96%) in the BI ≥60 group. The average age of subjects in the two groups was 87.47 ± 5.85 years and 83.26± 7.28 years, respectively. On univariate analysis, ADL impairment was associated with many factors, such as age, body mass index, blood lipid, heart rate, smoking history, Charlson comorbidity index (CCI), hemoglobin, serum albumin, BNP, eGFR, etc. Multivariate logistic regression showed that age (OR 1.08, 95% CI 1.00-1.17, P=0.0390), Charlson comorbidity index (OR 4.75, 95% CI 1.17-19.30, P=0.0295), and serum albumin (OR 0.80, 95% CI 0.70-0.92, P=0.0012) were the independent risk factors of ADL impairment.Decline of ADL in CKD patients was independently correlated with age, Charlson comorbidity index and serum albumin. ADL and its influential factors in the elderly CKD patients deserve further attention.© 2020 Chang et al.

Sloan JM

Goodbrand JA

, et al. Association between kidney function, rehabilitation outcome, and survival in older patients discharged from inpatient rehabilitation[J]. Am J Kidney Dis, 2015, 66(5): 768-774. DOI: 10.1053/j.ajkd.2015.04.041.

Chronic kidney disease (CKD) is common in older people, but it is unclear if it affects survival and rehabilitation outcomes independent of comorbid conditions and physical function in this population.Cohort analysis of prospective, routinely collected, linked clinical data sets.Patients discharged from a single inpatient geriatric rehabilitation center over a 12-year period.Admission estimated glomerular filtration rate (eGFR) category as a predictor of improvement in the 20-point Barthel score (activities of daily living measure) during rehabilitation; discharge eGFR category and Barthel score as predictors of survival postdischarge.Survival postdischarge was modeled using Cox regression analyses, unadjusted and adjusted for age, sex, morbidities (ischemic heart disease, chronic obstructive pulmonary disease, stroke, diabetes, and heart failure), Barthel score and eGFR category on discharge, and serum calcium, hemoglobin, and albumin levels. The effect of admission eGFR category on change in Barthel score during admission was modeled using analysis of covariance, adjusted for admission, Barthel score, and comorbid conditions.3,012 patients were included; mean age, 84 years. 2,394 patients died during a mean follow-up of 8.3 years. Compared with patients with eGFR of 60 to 89mL/min/1.73m(2), adjusted HRs for death were 1.26 (95% CI, 1.13-1.40), 1.45 (95% CI, 1.29-1.63), and 1.68 (95% CI, 1.42-1.99) for eGFR categories of 45 to 59, 30 to 44, and <30mL/min/1.73m(2), respectively. The relationship between discharge Barthel score and survival was similar within each discharge eGFR category (HRs of 0.95, 0.93, 0.92, 0.95, and 0.90 per Barthel score point within eGFR categories of ≥90, 60-89, 45-59, 30-44, and <30mL/min/1.73m(2); P for interaction = 0.2). Similar improvements in Barthel score between admission and discharge were seen for each admission eGFR category.Single-center study using routinely collected clinical data.eGFR category and Barthel score are independent risk markers for survival in older rehabilitation patients, but advanced CKD does not preclude successful rehabilitation.Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

目的通过回顾性队列研究，探讨血尿酸水平变化与肾功能的关系。方法通过佛山市第一人民医院的体检系统，提取佛山市一事业单位在2015年至2018年间的体检数据，获取受检者的性别、年龄、血常规、肝功能、血肌酐、尿酸、空腹血糖，观察估算肾小球滤过率（estimated glomerular filtration rate，eGFR）变化（ΔeGFR=eGFR2018-eGFR2015）情况。结果共2505位受检者完成了4年的随访，根据eGFR是否下降将受检者分为ΔeGFR≥0组和ΔeGFR＜0组，其中ΔeGFR≥0组共845人，ΔeGFR＜0组共1660人，比较发现在ΔeGFR≥0组其基础的尿酸值更高[（349.48±87.62）μmol/L比（325.72±82.58）μmol/L，t=6.669，P＜0.001]，其尿酸下降的幅度更大[-15.00（-53.50，17.00）μmol/L比15.50（-18.00，49.00）μmol/L，Z=-13.470，P＜0.001]。再根据2015年与2018年尿酸水平将受检者分为4组：均为正常组（N-N）、正常变为高尿酸组（N-H）、高尿酸降为正常组（H-N），持续为高尿酸组（H-H），其中N-N组1551例，N-H组299例，H-N组238例，H-H组417例，4组ΔeGFR分别为-1.58（-4.17，1.01）、-3.60（-7.24，-0.98）、-0.20（-3.14，3.27）、-0.96（-4.07，1.93）ml?min-1?(1.73 m2)-1，N-H组eGFR下降显著高于其余3组（χ2=103.130，P＜0.001）。多因素Logistic回归分析发现，尿酸升高是eGFR下降的独立危险因素（OR=1.739，95%CI 1.587～1.906，P＜0.001），而间接胆红素（OR=0.968，95%CI 0.943～0.993，P=0.013）、血红细胞（OR=0.815，95%CI 0.680～0.976，P=0.026）升高是eGFR下降的独立保护因素。结论尿酸升高是肾功能下降的独立危险因素，而良好地控制高血尿酸有助于保护肾功能。

Han QF

Zhu TY

, et al. The associations of uric acid, cardiovascular and all-cause mortality in peritoneal dialysis patients[J]. PLoS One, 2014, 9(1): e82342. DOI: 10.1371/journal.pone.0082342.

Fang Z

Yang M

, et al. Predictive value of serum uric acid levels on mortality in acute coronary syndrome patients with chronic kidney disease after drug-eluting stent implantation[J]. Cardiology, 2013, 125(4): 204-212. DOI: 10.1159/000350953.

Despite optimal treatments, prognosis in acute coronary syndrome (ACS) patients with chronic kidney disease (CKD) remains poor. Elevated serum uric acid (SUA) levels may predict worse outcomes in these patients. The objective was to assess the predictive value of SUA levels on mortality in ACS patients with CKD after drug-eluting stent (DES) implantation.We retrospectively assessed ACS patients with CKD who underwent successful DES implantation between January 2007 and December 2009. Patients were followed up from January to March 2012. CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2). We assessed the association between SUA levels and mortality.A total of 1,132 patients were included. The mean age was 67.7 years. During a mean follow-up of 38.5 months, 145 patients died: 50 from cardiac diseases, 28 from cerebral diseases, 14 from renal diseases and 53 from other causes. After adjustment for confounders, SUA levels increased the risk of all-cause, cerebral and other-cause mortality. Adjusted hazard ratios for quartiles 3 and 4 versus quartile 1 of SUA were: all-cause, 1.66 [95% confidence interval (CI) 1.08-2.78] and 1.99 (95% CI 1.21-3.23); cerebral, 2.24 (95% CI 0.43-11.7) and 5.89 (95% CI 1.30-26.6); and other causes, 2.81 (95% CI 1.17-6.78) and 3.89 (95% CI 1.63-9.29), respectively. SUA levels had no impact on cardiac and renal mortality rates.High SUA levels are associated with all-cause, cerebral and other-cause mortality rates in ACS patients with CKD after DES implantation. Future research is needed to determine if lowering SUA levels will decrease mortality in these patients.Copyright © 2013 S. Karger AG, Basel.

Yilmaz MI

Sonmez A

, et al. Serum uric acid independently predicts cardiovascular events in advanced nephropathy[J]. Am J Nephrol, 2012, 36(4): 324-331. DOI: 10.1159/000342390.

Chronic kidney disease (CKD) is associated with increased risk for cardiovascular (CV) disease and is also associated with elevated uric acid, which is emerging as a nontraditional CV risk factor. We therefore evaluated uric acid as a risk factor for CV disease in subjects presenting to nephrologists with CKD who were not on medications known to alter endothelial function.303 subjects with stage 3-5 CKD were followed for a mean of 39 months (range 6-46) and assessed for fatal and nonfatal CV events. Hyperuricemia was defined as uric acid >6.0 mg/dl for women and >7.0 mg/dl for men. In addition to other CV risk factors, endothelial function (flow-mediated dilatation), inflammatory markers (hsCRP), and insulin resistance (HOMA index and fasting insulin levels) were included in the analysis. We evaluated the association between uric acid and flow-mediated dilatation with linear regression. The impact of uric acid on composite CV events was assessed with Cox regression analysis.Of a total of 303 patients, 89 had normouricemia and 214 had hyperuricemia. Both fatal (32 of 214 vs. 1 of 89 subjects) and combined fatal and nonfatal (100 of 214 vs. 13 of 89 subjects) CV events were more common in subjects with hyperuricemia compared with normal uric acid levels, and this was independent of estimated glomerular filtration rate, traditional CV risk factors including diabetes, hypertension and BMI, and nontraditional risk factors (hsCRP and endothelial function). The 46-month survival rate was 98.7% in the group with low uric acid compared to 85.8% in patients with high uric acid (p = 0.002).Hyperuricemia is an independent risk factor for CV events in subjects presenting with CKD who are not on medications known to alter endothelial function.Copyright © 2012 S. Karger AG, Basel.

See LC

Yu KH

, et al. Significance of serum uric acid levels on the risk of all-cause and cardiovascular mortality[J]. Rheumatology (Oxford), 2013, 52(1): 127-134. DOI: 10.1093/rheumatology/kes223.

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