© Borgis - Postępy Nauk Medycznych 10/2015, s. 710-714
Grzegorz Ostrowski, Dorota Daniewska, *Ryszard Gellert
Długość życia i losy pacjentów z nowotworami złośliwymi rozpoczynających leczenie nerkozastępcze w latach 2001-2015 w doświadczeniu jednego ośrodka
Life span and outcomes in patients with malignant neoplasms commencing renal replacement therapy (RRT) in the years 2001-2015 – one-centre experience
Department of Nephrology and Internal Medicine, Center of Postgraduate Medical Education, P. Jerzy Popiełuszko Bielański Hospital, Warszawa
Head of Department: prof. Ryszard Gellert, MD, PhD
Streszczenie
Wstęp. Rosnąca dostępność leczenia nerkozastępczego może powodować wzrost częstości nowotworów złośliwych u pacjentów rozpoczynających to leczenie. Losy pacjentów z nowotworem rozpoczynających program przewlekłymi dializami nie były dotychczas wystarczająco analizowane.
Cel pracy. Analiza długości życia i losów pacjentów z nowotworami złośliwymi rozpoczynających leczenie nerkozastępcze. Dodatkowym celem była analiza przyczyn zgonów u tych chorych.
Materiał i metody. Przeprowadzono retrospektywną analizę zgromadzonej dokumentacji medycznej wszystkich pacjentów rozpoczynających w latach 2001-2015 (do 30 czerwca) leczenie dializami w Stacji Dializ DIAVERUM w Warszawie przy ul. Cegłowskiej 80, przy Szpitalu Bielańskim im. ks. J. Popiełuszki w Warszawie.
Wyniki. Podczas 174-miesięcznej obserwacji spośród 669 pacjentów (K-270, M-399) kwalifikowanych do powtarzanej dializoterapii, 84 (12,5%) miało nowotwór złośliwy pozostający w czasowej i/albo przyczynowej relacji z rozpoczynanym leczeniem. Możliwa była analiza losów 64 pacjentów dializowanych aż do końca obserwacji (5 zaprzestało leczenia hemodializami, u 5 częściowo powróciła czynność nerek, 10 zmieniło ośrodek dializ). Zmarło w czasie hemodializoterapii 57 z nich, u 1 wykonano przeszczepienie nerki, 6 kontynuuje hemodializoterapię (1-84 miesiące).
Wnioski. Leczenie nerkozastępcze powinno być rozpoczynane u pacjentów z nowotworami w sytuacji, kiedy pojawiają się do niego wskazania, tak jak w całej populacji osób z zaawansowaną chorobą nerek. Przeżywalność w tej grupie pacjentów jest względnie długa.
Summary
Introduction. The growing availability of renal replacement therapy (RRT) may rise the incidence of malignant neoplasms at commencement of chronic dialysis. The prognosis for such patients has not been studied extensively.
Aim. To analyse the life span and outcomes of patients commencing RRT with a coexisting malignant neoplasm. The secondary aim was to analyse the causes of death in this population.
Material and methods. The retrospective search of medical records from years 2001-2015 at the Diaverum Dialysis Unit (former Non-Public Health Care Unit “Centre of Dialysis and Diagnostics”) at the Priest J. Popiełuszko Bielański Hospital in Warsaw.
Results. Out of the 669 patients (F-270, M-399) who commenced chronic RRT (intention to treat) during the 174 months analysed, 84 (12.5%) had malignant neoplasm time- and/or cause-related to the RRT commencement. The outcomes were available in 64 patients on HD at the end of observation (20 patients were lost to follow-up – 5 discontinued HD, 5 partly recovered renal function, and 10 moved to another unit). Died 57 patients on the chronic haemodialysis therapy program (HD), 1 has been transplanted, and 6 continued the treatment started 1-84 months earlier.
Conclusions. Chronic haemodialysis should be initiated also in patients presenting with neoplastic disease whenever the indications to that treatment exist. In these patients the life expectancy can be quite long.
INTRODUCTION
Despite the increased life span of the chronically dialysed patients, which parallels the total population, not many studies devoted to haemodialysed (HD) patients report the influence of neoplastic disease on their survival (1-5). That is probably because qualifying the neoplastic patients to the chronic RRT would still result in much opposition in many countries. In places where access to the RRT is limited, qualification to the RRT program is more demanding, and the treatment is offered to patients with better prognosis. To the contrary, where one would be easy to find a possibility to dialyse, the ethical aspects of such a therapy, the interference of medicine into the human life, the permissibility of futile therapy, etc. are taken into consideration.
These, and probably many other factors influence the objective fact – there are not so many studies devoted to the neoplastic patients in demand of RRT. Moreover, these studies usually focus on particular oncologic disorders, and those on multiple myeloma outnumber the other (6, 7). Do these patients, in the common feeling representing much worse prognosis as compared to others, really live for such a short time that they emerge only in the very little number of papers? In many studies performed in dialysed patients, an influence of such parameters as age, quality and type of dialysis access, or different biochemical factors (e.g. haemoglobin, albumin, parathormon, C-reactive protein) on mortality would be analysed, but the coexisting neoplastic diseases is mentioned only seldom, if at all (8). Would really so few neoplastic patients commence the RRT program, do these patients have such a short expected life expectancy, or this particular group is so difficult to study?
AIM
The aim of this study was to analyse the life span and outcomes of patients commencing RRT with coexisting malignant neoplasm, for whom commencement of the RRT had been strictly related (time and/or cause relation) with a neoplastic disease. The secondary aim was to analyse the causes of death in this population.
MATERIAL AND METHOD
The retrospective search of all medical records of patients commencing dialysis due to the acute or chronic renal failure through the 174 month between January 1, 2001 and June 30, 2015 at the Diaverum Dialysis Unit (former Non-Public Health Care Unit “Centre of Dialysis and Diagnostics”) at the Priest J. Popiełuszko Bielański Hospital in Warsaw was performed.
RESULTS
In the years 2001-2015 (till June, 30) 669 adult patients (270 females and 399 men) initiated RRT with an intention to enter the chronic HD program. Out of these, 84 (12.5%) were diagnosed with neoplastic disease time- and/or cause-related with the beginning of RRT. For 14 patients (14/84, F-7, M-7) kidney dysfunction was acute (acute kidney injury – AKI). In 70 patients (70/84, F-18, M-52) the deterioration of kidney function was time-related to diagnosing the neoplasm. In the group of neoplastic patients commencing RRT (n = 84) the improvement of kidney function was observed in only 5 cases, all of them presenting with AKI (35.7% of AKI patients). Out of 79 patients demanding continuous haemodialysis therapy the outcomes of 64 patients on HD at the end of observation were analysed – 10 patients moved to other dialysis unit, 1 has been transferred to peritoneal dialysis, 4 stopped the RRT shortly after its initiation (in 1 case because of the lack of consent to continue, in 3 cases following the decision of the ethics committee with an intention to avoid persistent therapy). The observed outcomes were as follows: 57 of the 64 patients died on RRT program, 1 patient after the due time of deferment was successfully transplanted, 6 patients continued HD program lasting for 1-84 months, as of June 30, 2015 (fig. 1).
Fig. 1. Outcomes of 84 patients with active neoplastic disease commencing RRT in the years 2001-2015.
The deceased patients
Table 1 presents the characteristics of the population of deceased patients (n = 57), for whom HD was continued from the start of RRT despite the diagnosis of neoplastic disease. Indications to commence the RRT were classical. In case of AKI attempt to futile therapy was excluded, and in patients with chronic renal failure the general good condition, beside neoplastic disease, and predicted survival, were taken into consideration. Comparing the RRT and the conservative therapy’s pros and cons and the individual patient’s preferences were taken into account (including patients refusal and decision to interrupt therapy).
Most of the 57 continuously HD treated deceased patients, for whom RRT was initiated despite the coexist neoplastic disease and for whom start of the RRT was with independent time- and/or cause-related were of mean age of 69 ± 11.1 years. Males were a little bit older, and they also dominated the population in number. The largest group consisted of patients with haematological neoplasms – 16 persons (28.1%), including myeloma multiplex – 13 persons (22.8%). Another big group were patients with cancers of the urinary tract (kidney cancers, cancers of the bladder) – together 14 persons (24.6%). Males with prostate cancer numbered 9 persons (15.8%).
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Piśmiennictwo
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