Informing Our Elders About Dialysis

Abstract

SummaryAs the fastest growing sector of the incident ESRD population, older patients constitute a group for which renal replacement therapy has special implications. Older CKD patients have unique needs by virtue of advanced age, high prevalence of comorbid conditions, slower progression of renal disease, and reduced survival. Burdens and risks attendant to dialysis may be amplified in the older patient and patients with impaired functional status or comorbid conditions, and therefore, dialysis may confer little to no survival benefit. Rates of dialysis withdrawal are highest among the oldest patients, raising the possibility that the standard content of informed consent for dialysis warrants an age-sensitive approach that is attuned to the very different balance of pros and cons of dialysis for older patients with multiple comorbidities and younger patients with limited comorbidity. Informed consent for older patients should include presentation of risks, benefits, and burdens associated with dialysis, age-specific estimates of prognosis with and without dialysis, and potential for loss of independence and decline in functional status with initiation of dialysis. In this article, medical evidence and clinical practice guidelines relevant to advance care planning for the older patient with CKD are reviewed, issues to consider in the dialogue with older patients contemplating dialysis are presented, and recommendations for an age-attuned approach to informed consent for older CKD patients are made.

Risk of Catheter-Related Bloodstream Infection in Elderly Patients on Hemodialysis

“…Caring for elderly individuals with advanced CKD or end stage kidney disease (ESKD) encompasses complex medical decisions, including the choice of optimal hemodialysis (HD) vascular access (1,2). Although avoidance of tunneled central venous dialysis catheters (TCVCs) is a major goal in all HD patients, arteriovenous fistulae (AVFs) often fail to develop and/or are not used in the elderly (3,4).…”

Has the Yearly Increase in the Renal Replacement Therapy Population Ended?

“…Not only is the extent of competing mortality higher in patients age $75 years than in younger cohorts, but also these elderly patients may have a slower rate of renal function loss from an eGFR of 15 to ,10 ml/min per 1.73 m 2 . 7,10 In a prospective followup of a cohort with a mean age of 82 years and a mean eGFR of 14 ml/min per 1.73 m 2 , Moranne et al found that 43% of these patients could postpone dialysis initiation because of stable renal function. 11 …”

“…A nondialytic approach may be associated with a better preservation of functional status and residual renal function. 5,7 Most of the elderly dialysis population dies in acute care facilities. 6 If these patients are educated about a potential for a poor life quality on dialysis and the option for an intensive conservative care management program with more quality time at home, many may choose conservative management.…”

“…6 If these patients are educated about a potential for a poor life quality on dialysis and the option for an intensive conservative care management program with more quality time at home, many may choose conservative management. 5,7 One problem regarding conservative nondialytic management is the lack of adequate funding in the United States for "dialysis" medications and close followup. 6 A second problem is the lack of adequate training in palliative care for nephrology trainees.…”

“…3 We report on the most recent U.S. Renal Data System (USRDS) incident data that show a possible reversal of the early-start trend. 4 We consider the secular trend toward palliative nondialytic care in the elderly [5][6][7] and how this trend and a trend toward later dialysis start may affect future incidence of ESRD in the United States.…”