Dialysis may not be the best option for older people with kidney failure

Whether dialysis is the best option for kidney failure, and if so, when to start, may require more careful consideration, according to a new study.

Researchers at Stanford Medicine found that older adults who are not healthy enough to receive a kidney transplant can save about a week of life by starting dialysis when their kidney function falls below a certain threshold, rather than waiting. I discovered that I can get it.

Perhaps more significantly, in addition to the time they received dialysis, they also spent an additional two weeks on average in hospitals or nursing homes.

“Is that really what a 75- or 80-year-old patient wants?” he asked. maria montes lasPh.D., Senior Research Engineer.

Montez Rath is study About dialysis, life expectancy, and time at home Annual report of internal medicine August 19th. Tamura ManjulaM.D., professor of nephrology, is the lead author.

“It's really important for all patients, especially the elderly, to understand the trade-offs,” Tamura says. “They and their doctors need to carefully consider whether and when to continue dialysis.”

Patients with kidney failure who are healthy enough for a transplant can receive a donated kidney, where toxins and excess fluid are removed from the blood. But many older adults with additional health conditions, such as heart or lung disease or cancer, don't have that option available.

For these patients, doctors often recommend dialysis (a treatment that cleanses the blood like healthy kidneys) if the patient progresses to kidney failure. A patient is considered to have kidney failure if the estimated glomerular filtration rate (eGFR), a measure of kidney function, is below 15.

Dr. Montes Lass said patients and their families sometimes believe that dialysis is the only option or that it will significantly extend their lives. “They often say yes to dialysis without really understanding what it means.”

However, patients can take drugs instead of dialysis to manage symptoms of kidney failure, such as fluid retention, itching and nausea, Tamura said. He added that dialysis has side effects such as cramps and fatigue and usually requires three to four-hour clinic visits three times a week.

“This is a fairly intensive treatment that involves major lifestyle changes,” she says.

Lifespan and time at home

Researchers conducted this study to quantify the needs of dialysis for older people who are not candidates for transplants. This includes whether and how much dialysis prolongs life, as well as the relative number of days spent in inpatient facilities such as hospitals, nursing homes, and rehabilitation facilities. center.

The research team evaluated the health records of 20,440 patients (98% male) from the U.S. Department of Veterans Affairs from 2010 to 2018. Patients were 65 years of age or older, had chronic renal failure, were not being evaluated for transplantation, and had an eGFR <12.

We simulated a randomized clinical trial using electronic medical records, dividing patients into groups who started dialysis immediately and those who waited at least a month. Over three years, about half of the patients in the wait group did not start dialysis.

Patients who started dialysis immediately lived an average of nine days longer than those who waited for dialysis, but they spent 13 days longer in an inpatient facility. Age made a difference. Patients aged 65 to 79 who started dialysis immediately lived on average 17 days less and spent 14 days more in an inpatient facility. Patients over the age of 80 who started dialysis immediately lived 60 days longer on average, but spent 13 more days in an inpatient facility.

Patients who did not receive dialysis died on average 77 days earlier than those who started dialysis immediately, but they spent 14 days longer at home.

“This study shows that if you start dialysis right away, you may live longer, but you will spend more time on dialysis and are more likely to need hospitalization.” said Montes Lass.

Tamura pointed out that doctors sometimes recommend dialysis because they want to give patients hope, or because the downsides of the treatment are not always clear. However, this study shows that physicians and patients may want to wait until eGFR has fallen further and should consider symptoms and personal preferences before starting dialysis. Mr. Tamura said.

“Different patients have different goals,” she says. “For some people, having the option of dialysis is a blessing, but for others it can be a burden.”

She added that it may be helpful for clinicians to view dialysis for frail older adults as a palliative treatment primarily aimed at relieving symptoms.

“Currently, dialysis is often considered a life-or-death choice for patients,” she says. “When treatments are presented in this way, patients are left with no room to consider whether the treatment is aligned with their goals and tend to overestimate the benefit or well-being they may experience. But patients can more easily understand that there are trade-offs if the treatment is thought to be symptomatic.