American College of Physicians: Internal Medicine — Doctors for Adults ®


Dialysis might not be the right call for very old

From the September ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

As a nephrologist and geriatrician, T.S. Dharmarajan, FACP, understands the challenges of putting very elderly patients on dialysis. A few years ago, one of his patients, a wheelchair-bound diabetic, began dialysis two months before her 101st birthday.

“On dialysis, she substantially improved her function, activities of daily living and quality of life,” said Dr. Dharmarajan of New York Medical College. The patient continued dialysis for the next two and a half years.

More recently, Dr. Dharmarajan’s associate tried dialysis on a 102-year-old woman. After two weeks, dialysis had to be discontinued for the patient, who was demented and responding poorly. “We realized that if you continued this patient on dialysis, it was just going to make life miserable for the patient and everybody else around. Her quality of life was just not going to get better,” said Dr. Dharmarajan.

“The cases indicate the need for judgment in initiating dialysis in the old,” he noted. “All elderly are not alike.”

Dr. Dharmarajan’s dilemma—determining which elderly patients will benefit from dialysis—is a major issue for nephrologists that will only get bigger, according to a recent study published in Annals of Internal Medicine.

An increasing population

Increasing numbers of the very elderly are receiving dialysis, while overall survival remains low, the Feb. 6, 2007 Annals study concluded. Using statistics from the U.S. Renal Data System, the study found that the number of octogenarians and nonagenarians starting dialysis increased from 7,054 in 1996 to 13,577 in 2003. Controlling for population growth, researchers calculated a 57% increase in that period for new over-80 dialysis patients. But the one-year mortality after starting dialysis was 46%.

An article in the February 6 issue of Annals of Internal Medicine reported that dialysis is becoming more common among the very elderly in the U.S. The figure shows the incidence of dialysis initiation from 1996 to 2003 by year and age group, adjusted for sex and race.

The findings confirmed the anecdotal experiences which had motivated lead author Manjula Kurella Tamura, MD, MPH, and fellow nephrologists and geriatricians to undertake the study. “We observed ourselves taking care of more and more really elderly patients and we didn’t find any research documenting this growth or addressing the unique challenges posed by this population,” she said.

In addition to quantifying the growth of the elderly dialysis population, Dr. Kurella Tamura and colleagues looked at possible explanations for the increase. They found that average glomerular filtration rates (GFR) of patients entering dialysis were increasing, with the percentage of patients with an estimated GFR of 15 or more mL/min per 1.73 m2 increasing from 5% to 15% over the study period.

Manjula Kurella Tamura, MD, MPH, was the lead author of a study of dialysis for extremely elderly patients.

Manjula Kurella Tamura, MD, MPH, was the lead author of a study of dialysis for extremely elderly patients.

“Some of the trend to dialyze people earlier in the course of ESRD [end-stage renal disease] is applying to the elderly,” said Kenneth E. Covinsky, FACP, MPH, a geriatrician who also worked on the study. Although other studies have been inconclusive about whether there is any benefit to beginning dialysis earlier, the authors think that some clinicians are taking a preemptive approach with their elderly patients.

Another contributor to the trend may be the fact that more patients are surviving other health problems, such as myocardial infarctions, and going on to develop kidney disease, noted study co-author and nephrologist Glenn M. Chertow, FACP, MPH.

Dr. Chertow also attributes the increase to a shift in attitudes among patients and physicians. “I think some of it has to do with the very positive survival spirit that many people in America have. There’s a can-do attitude that people bring from their lives to their health care,” he said. “As we gain more and more experience with elderly persons on dialysis, I think nephrologists have become more comfortable with providing dialysis for the older old.”

Survival rates flat

Whether that positive attitude results in improved outcomes for patients is still in question.

The 46% mortality rate found in the Annals study did not change significantly over the seven-year timeframe and was found to significantly increase as the patient’s age increased. For example, patients ages 65-79 survive an average of 24.9 months after dialysis initiation, compared with 8.4 months for patients over age 90.

The researchers could not tell whether dialysis had any effect on the length of the patients’ lives, because the Renal Data System does not keep statistics on non-dialysis patients. That information would greatly help physicians who are trying to make decisions about treating elderly patients, but it is unlikely to be obtained in a randomized controlled trial, noted Dr. Kurella Tamura.

“It’s very difficult to do a randomized trial where you tell patients ‘I’m going to randomly decide whether you start dialysis now or a year from now.’ Patients don’t want that to be a random decision,” she said.

The lack of data on patients who do not get dialysis also concerned Fliss Murtagh, MRCGP, MSc., a British palliative care physician. “When you look at dialysis trends, you’re only looking at half the story,” she said.

Dr. Murtagh attempted to uncover the other half of the story with an English study published in Nephrology Dialysis Transplantation on April 4, 2007 of over-75-year-olds with stage 5 chronic kidney disease. The retrospective analysis compared survival rates between patients who underwent dialysis and those who opted for conservative management. The dialysis patients had a survival rate of 84% after one year and 76% after two years, compared with 68% and 47% in the conservative group.

Much of the survival advantage was lost, however, in patients who had a high rate of comorbidities, especially ischemic heart disease.

Dr. Murtagh was surprised by that finding, as well as the discovery that not all of the patients who opted for conservative management had high levels of comorbidity, since one would expect healthier patients to choose the more proactive treatment.

“We suspect there may be a group of fit, fairly well over-75s who want to avoid dialysis and stay out of the hospital regardless of the consequences for their survival,” she said.

Decisive factors

Comorbidities and patient preferences should be two of the biggest considerations when physicians are deciding whether to put a very elderly patient on dialysis, the experts agreed.

“They should separate the chronological age from the biological status of the patient,” said Dr. Dharmarajan. He noted that dementia, in particular, can dramatically affect whether a patient gets any improvement in function or quality of life from dialysis.

In evaluating the appropriateness of dialysis for a patient, “A useful starting point is the individual patient’s level of function prior to developing stage 5 kidney disease,” said Lisa Leinau, MD, a nephrologist and geriatrician at Yale University.

“If even prior to developing uremic symptoms the patient needed help with dressing, bathing, it’s likely that this dependence will persist. That can detract from the patient’s quality of life.”

Patients and their families will also often have strong opinions about whether they want dialysis, said Dr. Leinau. “I can think of patients who are frankly miserable and are doing it [dialysis] because their families really wanted them to keep living.”

Whether it makes patients miserable, or just inconvenienced and uncomfortable, the mechanics of dialysis often negatively impact quality of life, according to Michael J. Germain, MD, a nephrologist at Baystate Medical Center in Springfield, Mass. Patients have to sit still for hours at a time, and can experience side effects including headache, nausea, cramps, anemia, pruritus and insomnia.

“If it isn’t going to keep you living longer, certainly no one thinks dialysis is a fun thing to do,” said Dr. Germain.

Dr. Dharmarajan disagreed. “Some people will say it’s a headache, but many of the older patients on dialysis I have talked to love to get out of the nursing home. It’s variety in comparison to the monotonous day that they encounter in the nursing home. They look forward to seeing somebody different.”

Talking to patients

It takes a clinician with good communication skills to determine whether elderly patients will benefit or suffer from dialysis, the experts said.

“A lot of it is really being explicit about these situations,” said Dr. Covinsky. “Is this somebody who prefers length of life over everything? Or is this a patient who wants to focus less on life expectancy and more on quality of life?”

Physicians also need to be careful how they ask these questions, so as not to sway the results, noted Dr. Germain.

“It doesn’t mean saying, ‘Your kidneys failed. If you don’t have dialysis, you’re going to die. So do you want dialysis?’ If you put it that way, of course, people are going to say, ‘I don’t want to die.’” Given the uncertainty of data on whether dialysis actually prolongs elderly patients’ lives, that may be a false choice, he explained.

Dr. Murtagh also favors offering conservative management as a positive option. Conservative management can entail medication for symptoms, blood pressure and lipid control, low-protein diets—any treatment other than dialysis, as well as psychological and social care.

“We’ve started to introduce conservative management as another option alongside dialysis and transplantation in patient education sessions. I think that changes hugely how patients see it,” she said.

For patients who are on the fence, there is always the option of a short-term trial of dialysis. “I tend to encourage at least a trial of dialysis in individuals to whom I believe we can provide symptomatic benefit,” said Dr. Chertow.

Although the Annals study will not resolve the debate about whether to put elderly patients on dialysis, it does highlight the need for nephrologists to focus on palliative care in all cases, said Dr. Covinsky.

“One message to think about in this paper is that the life expectancy of patients with severe ESRD is short whether they get dialysis or not.”

Dr. Leinau agreed. “Palliative medicine should be an ongoing part of treatment for all patients with ESRD, regardless of their age. Pain, depression and sleep disturbance are highly prevalent, affecting around 50% of the dialysis population,” she said.

Dialysis and its costs

In the long term, the issue of whether to put 80- and 90-year-olds on dialysis is going to affect more than just the ESRD population.

“Obviously, dialysis is an expensive treatment,” said Dr. Murtagh. She noted that cost is a big, but often unspoken, issue in discussions over the value of dialysis for the elderly.

Although currently dialysis decisions in the U.S. and the United Kingdom are based on physician judgment and patient preference, the growth of the elderly ESRD population will increase financial pressures.

“There probably will come a stage when we as developed countries say the cost has to be a much greater consideration,” said Dr. Murtagh.

Experts want much more research to accurately calculate dialysis’ results and cost-effectiveness.

“A lot of the work on dialysis and a lot of the work on ESRD has been done on the young, and we have this exploding population of older patients. It really highlights the problem of older people being excluded from clinical trials,” said Dr. Covinsky.

Dr. Kurella Tamura would like to see more research on how practice guidelines apply to elderly patients, comparisons of outcomes between dialysis and conservative management patients, and trials of alternative methods of delivering dialysis.

Dr. Dharmarajan has worked with one such pilot—a nursing home in Manhattan that offers dialysis in-house. “The patient just goes in the wheelchair from the nursing home to the dialysis unit. It saves a lot of aggravation and cost for third-party payers,” he said.

That is the kind of innovation that Dr. Kurella Tamura wants to inspire with her research.

“I just hope we spur the healthcare system to think about how to address these problems going forward,” she said. “This population is only going to increase. How do we change our delivery of healthcare to address their unique and resource-intensive problems?”


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