Table of Contents
September 11, 2024
3 min read
Highlights:
- Elderly patients who chose dialysis rather than continued drug therapy lived longer.
- Patients who chose dialysis over medical therapy spent less time at home.
Older people with end-stage renal disease who started dialysis “slightly increased” their life expectancy compared with those who opted for continuous medical management, but spent less time at home, according to the study.
“Older people who start dialysis when their eGFR falls below 12 mL/min/1.73 m2 Patients who were not offered a transplant had a slightly longer life expectancy and spent less time at home.” Maria E. Montes-Ras, M.S., Ph.D. Researchers from the Department of Nephrology at the Stanford University School of Medicine said: Annals of Internal Medicine.
To determine whether outcomes with medical therapy are comparable to those achieved by choosing dialysis, researchers initiated the Targeted Trial Emulation study in patients aged 65 years or older with chronic kidney failure and an eGFR <12 mL/min/1.73 m who were treated at the U.S. Department of Veterans Affairs from 2010 to 2018.2 It was considered.
Patients started dialysis within 30 days of entering the study and were compared with a control group who received continued medical management.
The mean survival time and number of days at home were examined.
Better survival
The results showed that among 20,440 adults (mean age 77.9 years), “those who initiated dialysis survived for 770 days, compared with 761 days in those who continued medical management (a difference of 9.3 days). [95% CI, –17.4 to 30.1 days]”Compared with the group that continued medical management, the group that initiated dialysis spent 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home),” the researchers wrote.
The researchers note that clinicians can use the findings to help patients decide between treatment options.
“Whether and when to undergo intensive care such as dialysis is a complex and dynamic decision,” the researchers wrote. “Patients may implicitly assume that treatments that extend survival also increase independence, or that increased life expectancy outweighs time spent in hospital or intensive care. Using the best available methods to account for biases and confounding factors, our study highlights the trade-off between survival and time spent at home associated with initiating dialysis,” they wrote.
Medical Management Education
The authors also suggested that the results should lead to improved patient education regarding medical management as an alternative to dialysis. “These results have several implications for clinical practice and policy,” the authors wrote. “First, by focusing on the life-prolonging benefits of dialysis, treatment decisions for older adults with renal failure often ignore or downplay the potential harms of dialysis, including exposure to invasive procedures, hospitalization, and time spent in the medical setting,” the authors wrote. “The consequences of poor decision-making have been documented in numerous studies: patients hold unrealistic expectations about the benefits of treatment and experience strong regret and withdrawal from treatment soon after initiating it.
“Furthermore, these results highlight the importance of a comprehensive and balanced approach to nephrology education for patients who are not suitable for transplant,” the authors wrote.
In an editorial accompanying this article, the authors write: Victoria J. Leal Tong, BN, Cumming School of Medicine, University of Calgary Sofia B. Ahmed, MD, MSc, A study by Montes Ras, professor of medicine and dentistry at the University of Alberta, said:[a]The elderly [chronic kidney disease] In CKD, longer life span, reduced symptom burden, and achieving maximum social and functional life participation may become a higher priority.
“The findings of Montes-Las and colleagues not only reveal important trade-offs associated with initiating dialysis, but also that older adults with advanced CKD are at increased risk of mortality regardless of whether they initiate dialysis, highlighting the critical importance of ongoing discussions about goals of care among patients, their families, caregivers, and healthcare providers,” the researchers wrote. – Mark E. Newman
perspective
Montes-Las et al.'s study is one of the first in the United States to focus on the decision between dialysis and medical management for older adults with kidney failure. The authors deserve credit for highlighting a critical decision and incorporating health priorities other than survival as outcomes. The bottom line is that survival with dialysis exists, but it is modest and is associated with less time spent at home.
Health priorities for adults with CKD have previously been shown to include factors other than survival, such as maintaining independence. Days spent at home is one outcome, but the impact on this is likely an underestimate as it does not include time spent undergoing dialysis in a centre for at least 3 hours three times a week, and travel time to and from treatment, which may increase substantially over the course of months to years.
The extent of support provided to the group of patients in this study who opted for continuing medical management is unknown. In other countries, more structured conservative management occurs with multidisciplinary practice incorporating palliative care principles in patient and family support to help manage symptoms and transitions in care.
This study should spark an important dialogue between patients, caregivers, and healthcare providers when discussing the management of advanced kidney disease. May other researchers continue to evaluate these results, the best ways to support decision-making, and how to best care for patients who choose non-dialysis therapies.
Holly M. Kontick, MD
Associate Professor
Barbara T. Murphy Nephrology
Brookdale Geriatrics and Palliative Medicine
Icahn School of Medicine at Mount Sinai
Editorial Advisory Board Member
Healio | Kidney Disease News and Issues
Disclosure: Koncicki reported no relevant financial disclosures.
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Disclosure: The authors report no relevant financial disclosures. This research was primarily funded by the Department of Veterans Affairs and the NIH.
