Post on 17-Jul-2018
The time of initiation of
dialysis in elderly patients
Behzad Einollahi
Professor of Nephrology
Baqiyatallah University of Medical Sciences
Incidence and Prevalence
In the recent years, increased numbers of older
pts have initiated dialysis worldwide in terms of
both absolute numbers and rates per million
population.
Dialysis initiation rates are reported at 1744 per
million population for those aged 75 yr.
USRDS Data Report: Incidence and Prevalence.
• The optimal timing of initiation of dialysis therapy remains an unresolved issue among nephrologists.
• Indications for initiation of dialysis in CKD dialysis involves the consideration of subjective and objective parameters by the physician and the patient.
These parameters are often modulated by the patient's perception of his or her quality of life and by possible anxiety about starting new therapy that is technologically complex.
There are no absolute levels of kidney function that indicate a requirement for dialysis; as such, the decision to initiate dialysis may be a complex one that the physician must make in conjunction with the patient.
The decision to start dialysis is
generally guided by
clinical data such as uremia symptoms, signs of protein–energy wasting or fluid
overload
the measures of renal function, most often eGFR from serum creatinine
Timing of initiation of dialysis among
asymptomatic CKD patients
There is no specific threshold GFR level that has been established for the initiation of dialysis.
However it should be considered in the asymptomatic patient with eGFR 8 to 10 mL/min per 1.73 m2.
Some clinicians may choose to closely monitor (weekly) asymptomatic pts with progressive
CKD even when GFR is below this level, with the initiation of dialysis upon the onset of
uremic signs/symptoms.
Updated guidelines from2006
dialysis should start before CKD stage 5 (GFR <15
mL min )
if pts have symptoms
believed to be elated to a
combination of existing
comorbidities and insufficient renal
function
Does early dialysis or referral improve
survival/outcomes?
Some retrospective and uncontrolled
prospective studies have reported a
benefit associated with early initiation
whereas others have reported
increased mortality.
In recent years, there has been a shift towards
an earlier start in both Europe and the USA.
However, recent observational studies
unable to confirm any benefit of early
dialysis initiation. pts starting the dialysis at a lower eGFR level survived significantly
longer.
a recent meta-analysis that included four randomized controlled trials and 19
observational studies conducted over four decades suggested that early dialysis
initiation may have a beneficial effect on
survival.
In the publication by Stel et al. data from European registries are
presented which show that the lower the eGFR at the start of dialysis, the better the outcome
(in terms of longer survival).
“no benefit from early start of dialysis”
interpretation is that the increased mortality
before and after initiation of dialysis may be a
result of
dialysis-induced silent MI
HD is an independent risk factor for the development of CHF and cardiac death
Problems
Elderly pts who are on dialysis seem to have a
higher burden of age-related problems, or
“geriatric syndromes,” such as frailty, falls, and
cognitive impairment.
There is also emerging evidence that dialysis
initiation may be associated with accelerated
rates of functional and/or cognitive decline.
frailty
The term “frailty” is used to describe
patients with sarcopenia, weakness, weight
loss, and functional decline.
Frail individuals are at high risk for
increased morbidity, hospitalization,
nursing home placement, and mortality.
Fried LP, et al. J Gerontol A Biol Sci Med Sci 56: M146–M156, 2001
frailty
Individuals who were older than 65 yr,
those with impaired renal function were
shown to be at higher risk for frailty than
those with normal renal function (15 versus
6%, respectively)
Shlipak MG, et al. Am J Kidney Dis 43: 861–867, 2004
frailty The data showed an inverse relationship between the
prevalence rates for frailty and the level of renal
function.
Dialysis pts have been shown to experience one of the
highest prevalence rates for frailty.
In the Dialysis Morbidity and Mortality Study (DMMS)
Wave II study, a total of 67.7% of patients of all ages
met collective criteria for frailty.
Johansen KL, et al. J Am Soc Nephrol 18: 2960–2967, 2007
Accidental Falls
Fall incidence rates have been estimated
between 1.2 to 1.6 falls per person-year
for dialysis pts with older than 65 yr.
It is interesting that falls were associated
with a two-fold risk for mortality.
Functional Decline and Disability
Loss of independent functioning and high
levels of dependence have been recognized
in older individuals who are on dialysis.
High dependence has been reported in
elderly prevalent dialysis pts: More than
50% of patients required help with at least
one aspect of personal care.
Cognitive Function
Brain function has been seen to be
affected by the presence of CKD, such
that as kidney disease progresses,
cognitive function declines.
The effect of ESRD on life expectancy
Data from the USRDS indicate that pts
aged 65 or more undergoing dialysis have a
life-expectancy of approximately four
years, which is markedly lower than that of
a patient of the same age without ESRD.
USRDS. Am J Kidney Dis 2006; 47(Suppl 1):S1.
The effect of ESRD on life expectancy
The impact of ESRD on life
expectancy generally decreases
with increasing age.
Balancing Benefit and Burden
The benefit of dialysis is undoubtedly
prolonged survival in those with ESRD.
In Canada, pts who started dialysis when
they were aged 75-80 yr had a 14%
increase in life expectancy (average life
expectancy 3.19 yr vs 2.73 yr).
Jassal SV, et al. CMAJ 177: 1033–1038, 2007
Balancing Benefit and Burden
The prognosis with dialysis
treatment is similar to that of
colorectal cancer and only
marginally better than that of lung
cancer.
Jassal SV, et al. CMAJ 177: 1033–1038, 2007
Balancing Benefit and Burden
Dialysis care offered only marginal benefits
Median survival 8.3 versus 6.3 mo for those
who opted for dialysis care compared with
those who accepted palliative care
recommendations, respectively.
Smith C, et al. Nephron Clin Pract 95: c40–c46, 2003
The effect of ESRD on
quality of life
Despite limited survival for some pts,
many elderly pts have a high quality of
life on dialysis, lending support to the
policy of the continued offering of
ESRD therapy to these pts.
Elderly people form the fastest growing
segment of the dialysis population.
often refer late for dialysis
have several comorbid conditions
are at risk of cognitive dysfunction
declining vision
Nutrition is major problem
undergo dialysis treatment that will
most likely prolong their life
or to decline dialysis which could mean
dying sooner
Challenge for the nephrologist to decide
whether starting dialysis
when there are multiple
comorbidities.
Will dialysis prolong life?
If it does, will it be at the
expense of quality of life?
Poor prognostic factors in this population
Non-ambulatory
statusimpaired
intellectual status
diabetes
low serum albumin
peripheral vascular disease
late referral for ESRD treatment
Older age
Conservative care
Such patients continue to be followed in renal clinics with active management focusing on anemia, fluid status and symptom control.
Nonaggressive Renal Care and
End-of-Life Care
This term is a conservative care.
Providing care at the end of life is
an important aspect of
comprehensive geriatric
nephrology care.
Nonaggressive Renal Care and
End-of-Life Care
Aggressive management of non–renal-
specific symptoms such as pain and
depression are essential, and involvement
of the palliative care service is
recommended.
Discontinuing Dialysis
Withdrawal from dialysis is a common
cause of death among elderly pts with
ESRD.
The rate of voluntary withdrawal from
dialysis increases with age.
Modality Choices
The use of PD in elderly pts may be controversial.
Although the worldwide use of PD has declined,
11.6% of pts aged 75 yr in Canada and 15% of pts
aged 65 yr in the U.K. are started onto PD as their
initial dialysis modality.
2009 UK renal registry: Initial dialysis modality.
2007Annual Report: Treatment of End-Stage Organ Failure in Canada, 1996–2005.
Modality Choices
Reports suggesting that elderly women with
diabetes experience higher mortality when
treated with PD as their initial dialysis modality
are of concern.
The data showing an increased mortality risk
would likely shorten life only by a few weeks to
months in contrast to a potentially improved
quality of life.Vonesh EF, et al. Kidney Int Suppl S3–S11, 2006
Choice of therapy
Compared with younger pts, older individuals
are more likely to initiate renal replacement
therapy with HD.
In one single center study, pts older than 75 years
of age were more frequently treated by HD than
PD (81% vs 19%) when compared to their
younger counterparts (65% vs 35%).
Létourneau I, et al. Renal replacement in end-stage renal disease
patients over 75 years old. Am J Nephrol 2003; 23:71.
Treatment of elderly ESRD pts (>75
yr) In USA
In-center hemodialysis: 96%
Continuous ambulatory peritoneal dialysis
or continuous cycler peritoneal dialysis
(CAPD/CCPD): 3.5%
Home hemodialysis: 0.3%
USRDS. Am J Kidney Dis 2006; 47(Suppl 1):S1.
Mortality rate
Mortality in the first year after the
initiation of dialysis exceeds 35%
among pts older than 70 years of age
and exceeds 50% among pts older than
80 years of age.
Tamura MK, et al. Functional Status of Elderly Adults before and after
Initiation of Dialysis N Engl J Med 2009; 361:1539-1547.
Among nursing home residents
with ESRD, the initiation of
dialysis is associated with a
substantial and sustained decline
in functional status in addition to
very high mortality.
Tamura MK, et al. Functional Status of Elderly Adults before and after
Initiation of Dialysis N Engl J Med 2009; 361:1539-1547.
OUTCOMES OF
HEMODIALYSIS
Despite complex comorbid and
psychosocial conditions, survival
and the quality of life in the elderly
patient on HD is frequently
acceptable.
OUTCOMES OF HEMODIALYSIS
Observational studies have found significantly
improved survival in elderly pts who initiated
dialysis versus those treated conservatively.
An observational single center study of 202
elderly pts with ESRD found higher median
survival among those who underwent dialysis
versus pts treated conservatively (38 vs 14
months, respectively).
Carson RC,et al. Clin J Am Soc Nephrol 2009; 4:1611.
OUTCOMES OF HEMODIALYSIS
An acceptable subjective quality of
life and degree of rehabilitation
have also been noted in many other
reports.
Panarello G, et al. Adv Perit Dial 1989; 5:49.
OUTCOMES OF HEMODIALYSIS
One study of 3701 nursing home residents who
initiated dialysis found that, one year after
dialysis was begun, nearly 60% had died and
only 13% had maintained their predialysis
functional status.
Thus, frail elderly nursing home residents
perform relatively poorly with maintenance
dialysis, particularly if effective rehabilitation is
not performed.
Outcomes among the very old
In one study from the USRDS, the one-year
mortality of pts aged 80 and older was 46%,
which had not changed in the period from 1996
to 2003.
Independent predictors of poor survival among
the very old include older age, poor nutritional
status, nonambulatory status, late referral for
dialysis initiation, and the presence of significant
comorbid conditions, particularly cardiovascular
diseaseKurella M, et al. Ann Intern Med 2007; 146:177.
Malnutrition
The incidence of malnutrition among
dialysis pts may be higher among the
elderly than younger pts.
Malnutrition among all dialysis pts,
including the elderly, is associated with
decreased survival.
Infection
The elderly are at an increased risk for
infections due in part to aging of the
immune system and the effect of poor
nutrition on overall immune function.
Such infections result in significant
morbidity and mortality among these pts.
Gastrointestinal Bleeding
Elderly pts have an increased incidence
of diverticulosis, angiodysplasia, and
carcinoma.
These lesions can contribute to a
higher incidence of GI bleeding when
on dialysis.
SUMMARY AND
RECOMMENDATIONSDespite limited survival for some pts, many
elderly pts have a high quality of life on
dialysis, lending support to the policy of the
continued offering of ESRD therapy to
these pts.
Most elderly pts would also choose dialysis
therapy if given the therapeutic option,
particularly if symptoms were relieved and
independence was maintained.
SUMMARY AND
RECOMMENDATIONS
Dialysis should therefore not be denied to
elderly pts, even the very old, if there is
hope for prolongation of an enjoyable span
of life.
When there is doubt about chances of
recovery from a severe underlying disease,
a "trial" of dialysis may be offered.
SUMMARY AND
RECOMMENDATIONSWithdrawal of dialysis at a later time is
preferable to withholding it from the
beginning.
The major contraindications to dialysis
are advanced malignancy (with the
possible exception of multiple
myeloma) or irreversible dementia or
advanced liver disease.
dialysis start should be based
on clinical factors rather than
numerical criteria such as the eGFR
alone