Four Plus Forty-Four

Jassal, Sarbjit V.

doi:10.2215/cjn.12681214

Cited by 4 publications

(2 citation statements)

References 23 publications

(35 reference statements)

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“…52–55 They argue in favor of care that includes close attention to modifiable symptoms, such as pain or weakness, in an attempt to improve functional status, as well as, perhaps furthering discussions about the value of care that prioritizes symptom management over laboratory-target driven dialysis care. We also observed that patients with advanced functional dependence were more likely to withdraw from dialysis, a finding that is consistent with the clinical impression that both patients and caregivers experience a low QOL when a large amount of assistance with daily tasks are required.…”

Section: Discussionmentioning

confidence: 99%

Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS)

Jassal

Karaboyas

Comment

et al. 2016

American Journal of Kidney Diseases

134

136

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Background Patients on chronic dialysis have among the highest mortality and hospitalization rates. In the non-renal literature, functional dependence is recognized as a contributor to subsequent disability, recurrent hospitalization, and increased mortality. A higher burden of functional dependence with progressive worsening of renal function has been observed in several studies, suggesting functional dependence may contribute to both morbidity and mortality in dialysis patients. Study Design Prospective cohort study Setting & Participants 7,226 hemodialysis patients from 12 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 4 (2009–2011) with self-reported data on functional status (FS). Predictor Patients’ ability to perform 13 basic and instrumental Activities of Daily Living (ADL) was summarized to create an overall FS score ranging from 1.25 (most dependent) to 13 (functionally independent). Outcome Cox regression was used to estimate the association between FS and all-cause mortality, adjusting for several demographic and clinical risk factors for mortality. Median follow-up was 17.2 months. Results The proportion of patients who could perform each ADL task without assistance ranged from 97% (eating) to 47% (doing housework). 36% of patients could perform all 13 tasks without assistance (FS=13), and 14% of patients had high functional dependence (FS < 8). Functionally independent patients were younger and had many indicators of better health status including higher quality of life. Compared with functionally independent patients, the adjusted hazard ratio for mortality was 2.37 (95% confidence interval =1.92–2.94) for patients with FS < 8. Limitations Possible non-response bias and residual confounding Conclusions We found a high burden of functional dependence across all age groups and across all DOPPS countries. When adjusting for several known mortality risk factors, including age, access type, cachexia and multi-morbidity, functional dependence was a strong, consistent predictor of mortality.

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Section: Discussionmentioning

confidence: 99%

Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS)

Jassal

Karaboyas

Comment

et al. 2016

American Journal of Kidney Diseases

134

136

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“…Some authors have reported that with integrated clinical management, including nutritional management and optimization of symptomatic treatment, survival rates are comparable to those obtained with dialysis [ 7 – 12 ]. This option is often called “palliative care” or “conservative care” and some authors maintain that it should be offered as an alternative to dialysis to fragile patients with “terminal” end-stage renal disease (ESRD) [ 8 – 14 ]. The results are not always easy to interpret, as the choice of palliative care may be an indication of subtle fragilities or of a nihilist, depressive attitude, both associated with lower survival.…”

Section: Introductionmentioning

confidence: 99%

The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions

2017

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BackgroundStarting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions.Case presentationMr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy).In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”.ConclusionsAn individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.

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Cost of renal replacement: how to help as many as possible while keeping expenses reasonable?

Vanholder¹,

Lameire²,

Annemans³

et al. 2015

Nephrol. Dial. Transplant.

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The treatment of kidney diseases consumes a substantial amount of the health budget for a relatively small fraction of the overall population. If the nephrological community and society do not develop mechanisms to contain those costs, it will become impossible to continue assuring optimal outcomes and quality of life while treating all patients who need it. In this article, we describe several mechanisms to maintain sustainability of renal replacement therapy. These include (i) encouragement of transplantation after both living and deceased donation; (ii) stimulation of alternative dialysis strategies besides classical hospital haemodialysis, such as home haemodialysis, peritoneal dialysis or self-care and necessitating less reimbursement; (iii) promotion of educational activities guiding the patients towards therapies that are most suited for them; (iv) consideration of one or more of cost containment incentives such as bundling of reimbursement (if not affecting quality of the treatment), timely patient referral, green dialysis, start of dialysis based on clinical necessity rather than renal function parameters and/or prevention of CKD or its progression; (v) strategically planned adaptations to the expected growth of the ageing population in need of renal replacement; (vi) the necessity for support of research in the direction of helping as large as possible patient populations for acceptable costs; and (vii) the need for more patient-centred approaches. We also extend the discussion to the specific situation of kidney diseases in low- and middle-income countries. Finally, we point to the dramatic differences in accessibility and reimbursement of different modalities throughout Europe. We hope that this text will offer a framework for the nephrological community, including patients and nurses, and the concerned policy makers and caregivers on how to continue reaching all patients in need of renal replacement for affordable expenses.

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Four Plus Forty-Four

Cited by 4 publications

References 23 publications

Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS)

Functional Dependence and Mortality in the International Dialysis Outcomes and Practice Patterns Study (DOPPS)

The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions

Cost of renal replacement: how to help as many as possible while keeping expenses reasonable?

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