Patients who started dialysis lived on average 77 days longer than those who did not start dialysis.
A new study found that dialysis can extend the lifespan of patients with kidney failure in old age, but the effect is smaller than expected. The New York Times (NYT) reported on the 1st (local time) based on a paper by American researchers published in the Annals of Internal Medicine.
A team led by Stanford University nephrologist Manjula Tamura analyzed data from a simulated trial of more than 20,000 elderly patients (average age: about 78) from the Veterans Health Care System. The results showed that the increase in survival among dialysis patients was “only marginal.”
Over a three-year period, elderly patients with renal failure who started dialysis immediately lived an average of 770 days, just 77 days longer than those who did not start dialysis. Patients who started dialysis also spent about 15 days longer in hospitals, nursing homes, or rehabilitation centers than those who did not start dialysis, and spent less time at home.
Another group continued with ‘medical management’ (treatment intervention to relieve symptoms when necessary) without starting dialysis early, but half of them started dialysis later. These people survived for about the same amount of time as the group that started dialysis right away.
“In our field, there has been a lot of discussion about the role of dialysis in patients with kidney disease in the elderly,” said Professor Tamura. “Dialysis is a lifelong treatment and it involves a major change in lifestyle.” He explained that dialysis “can extend life, but it has its pros and cons.”
According to the U.S. Kidney Data System, about one-third of people over age 65 have chronic kidney disease. For these people, the pros and cons of treatment are different than for younger patients. Most older people who develop kidney failure also have diabetes, and many also have heart failure, lung disease, or other serious chronic conditions. They are less likely to be eligible for kidney transplantation, the only cure for kidney failure, because they are too sick or too weak to undergo surgery, or because the wait for a donated kidney can take years.
About 13% of patients with renal failure registered in the Renal Data System begin peritoneal dialysis at home. Although it is a more common treatment in other countries, interest in peritoneal dialysis is increasing in the United States as Medicare incentives are available. Peritoneal dialysis is a treatment that filters blood through the abdominal wall.
However, as of 2021, the majority of dialysis patients, approximately 84%, still use dialysis centers despite the difficulties in transportation and the considerable time required. Hemodialysis provided at dialysis centers requires catheters, grafts, or fistulas to access the patient’s blood vessels, and can cause side effects such as infections, fatigue, and itching. And, as a new study shows, dialysis requires more time spent in a medical center, which most older adults do not want to spend. Dialysis at a dialysis center requires three visits a week, and each visit takes several hours to remove waste products and excess fluid from the blood.
Alternatives to dialysis go by a variety of names, including medical management, conservative renal care, and assisted renal care. A nephrologist monitors the patient’s health, educates them on behavioral approaches, and prescribes antiemetics such as Zofran and diuretics such as Lasix to reduce fluid retention, adjusting the doses as needed.
Dr. Rashida Hall, a geriatric nephrologist in the United States, said patients who choose conservative management “get more attention, but they sleep in their own beds,” and “they’re not hospitalized as often, so their quality of life is better.” Some older kidney patients prefer this treatment even if it means having their deaths accelerated by months. But patients are rarely given a choice, Dr. Tamura said.
Researchers at the University of Washington in the United States created a booklet called a ‘decision aid’ that explains conservative kidney care and its pros and cons and tested it on patients with advanced kidney disease aged 75 or older and their families. The goal was to encourage discussions about conservative care with their medical team.
In the group that received the booklet, about 25% of patients and their families had such a conversation. However, among the patients who did not receive the booklet, only 3% of patients discussed conservative management with their medical team, and none of their family members had such a conversation.
“The results are encouraging,” said Susan Wong, a nephrologist at Washington University School of Medicine and the lead author of the paper. She said that in her clinic, about a third of patients visit a dialysis center, a third start peritoneal dialysis at home, and a third choose conservative management without dialysis.
Practices are also changing among kidney patients and doctors. For example, the most recent statistics from the U.S. Renal Data System show that the use of home peritoneal dialysis more than doubled between 2008 and 2021. The proportion of patients visiting dialysis centers has decreased accordingly.
Dr. Kevin Abbott of the National Institute of Diabetes and Digestive Diseases (NIDDK) said that the percentage of older people with kidney disease has decreased in recent decades as more effective blood pressure medications have become more widely available. New diabetes drugs that help reduce weight and blood sugar also show promise in treating kidney disease. But it is still up to patients and their families to decide whether to start dialysis, ask about other options such as conservative kidney care, and weigh their options, the NYT reported.
The paper can be found at the following link (
Source: kormedi.com
