Outcome of renal replacement therapy in the very elderly

Munshi, Sunil; Vijayakumar, Narayanaswamy; Taub, Nicholas; Bhullar, Harneeta; Lo, Tim; Warwick, Graham

doi:10.1093/ndt/16.1.128

Cited by 103 publications

(84 citation statements)

References 18 publications

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“…It is however of interest that-in agreement with the general population-elderly dialysis patients were more likely to have high Center of Epidemiologic Studies Depression Rating Scale scores in Europe and in Japan, indicating the higher likelihood of possible clinical depression among elderly hemodialysis patients. As expected, mortality rates were higher in elderly hemodialysis patients (28). Median survival for patients aged Ն75, 45 to 74, and Ͻ45 years was 3, 6, and 12 years, respectively.…”

Section: Discussionsupporting

confidence: 77%

Clinical Practices and Outcomes in Elderly Hemodialysis Patients

Canaud

Lin

Tentori

et al. 2011

Clinical Journal of the American Society of Nephrology

219

164

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SummaryBackground and objectives Demand for hemodialysis among elderly patients is increasing worldwide. Although clinical care of this high-risk group is complex and challenging, no guidelines exist to inform hemodialysis practices. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to assess dialysis practices and associated outcomes among elderly versus younger patients on chronic in-center hemodialysis in 12 countries. Results Although participant mean age increased over time in all DOPPS countries, the percentage of elderly varied widely. Overall, comorbidities and malnutrition were more common in the elderly. Fistulae were used less frequently among elderly versus younger patients in Europe and North America but not in Australia, New Zealand, and Japan. No difference in treatment time was observed between elderly and younger patients after normalizing for body weight. In all regions, ultrafiltration rates were lower among elderly patients. Elderly patients reported poorer quality of life with respect to the physical but not mental component scores. Mortality risk was three-to sixfold higher in the elderly group, whereas causes of death overall were similar for elderly and younger patients. Design, setting, participants, & measurements ConclusionsElderly patients represent a different proportion of DOPPS participants across countries, possibly reflecting differences in policies and clinical practices. In general, hemodialysis practices in the elderly reflected each region's clinical patterns, with some variation by age group depending upon the practice.

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Section: Discussionsupporting

confidence: 77%

Clinical Practices and Outcomes in Elderly Hemodialysis Patients

Canaud

Lin

Tentori

et al. 2011

Clinical Journal of the American Society of Nephrology

219

164

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“…It has been reported that the 1-year survival of those patients .75 years old on HD is 53.5%, whereas at 5 years, it is as low as 2.4%. 16,17 Overall, our data suggest that fistula first is not the clearly superior strategy in the elderly population, particularly for octogenarians and nonagenarians. However, our data support the notion that placing a catheter first does seem to be the 19,20 Using this time to plan and create a fistula or graft seems prudent.…”

Section: Discussionmentioning

confidence: 77%

Fistula First Is Not Always the Best Strategy for the Elderly

DeSilva

Patibandla

Vin

et al. 2013

Journal of the American Society of Nephrology

157

115

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Whether placing a fistula first is the superior predialysis approach among octogenarians is unknown. We analyzed data from a cohort of 115,425 incident hemodialysis patients $67 years old derived from the US Renal Data System with linked Medicare claims, which allowed us to identify the first predialysis vascular access placed rather than the first access used. We used proportional hazard models to evaluate all-cause mortality outcomes based on first vascular access placed, considering the fistula group as the reference. In the study population, 21,436 patients had fistulas as the first predialysis access placed, 3472 had grafts, and 90,517 had catheters. Those patients with a catheter as the first predialysis access placed had significantly inferior survival compared with those patients with a fistula (HR=1.77; 95% CI=1.73 to 1.81; P,0.001). However, we did not detect a significant mortality difference between those patients with a graft as the first access placed and those patients with a fistula (HR=1.05; 95% CI=1.00 to 1.11; P=0.06). Analyzing mortality stratified by age groups, grafts as the first predialysis access placed had inferior mortality outcomes compared with fistulas for the 67 to #79-years age group (HR=1.10; 95% CI=1.02 to 1.17; P=0.007), but differences between these groups were not statistically significant for the 80 to #89-and the .90-years age groups. In conclusion, fistula first does not seem to be clearly superior to graft placement first in the elderly, because each strategy associates with similar mortality outcomes in octogenarians and nonagenarians.

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“…This is surprising, in light of the fact that ESRD patients have a high annual mortality rate (1). Moreover, hospitalizations and complications are common, and many patients have some degree of cognitive impairment (3,20,21). For all of these reasons, advance directives are likely to be particularly useful in this population.…”

Section: Discussionmentioning

confidence: 99%

Survival after Dialysis Discontinuation and Hospice Enrollment for ESRD

O’Connor

Dougherty

Harris

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Textbooks report that patients with ESRD survive for 7-10 days after discontinuation of dialysis. Studies describing actual survival are limited, however, and research has not defined patient characteristics that may be associated with longer or shorter survival times. The goals of this study were to determine the mean life expectancy of patients admitted to hospice after discontinuation of dialysis, and to identify independent predictors of survival time.Design, setting, participants, & measurements Data for demographics, clinical characteristics, and survival were obtained from 10 hospices for patients with ESRD who discontinued dialysis before hospice admission. Data were collected for patients admitted between January 1, 2008 and May 15, 2012. All hospices were members of the Coalition of Hospices Organized to Investigate Comparative Effectiveness network, which obtains de-identified data from an electronic medical record.Results Of 1947 patients who discontinued dialysis, the mean survival after hospice enrollment was 7.4 days (range, 0-40 days). Patients who discontinued dialysis had significantly shorter survival compared with other patients (n=124,673) with nonrenal hospice diagnoses (mean survival 54.4 days; hazard ratio, 2.96; 95% confidence interval, 2.82 to 3.09; P,0.001). A Cox proportional hazards model identified seven independent predictors of earlier mortality after dialysis discontinuation, including male sex, referral from a hospital, lower functional status (Palliative Performance Scale score), and the presence of peripheral edema.Conclusions Patients who discontinue dialysis have significantly shorter survival than other hospice patients. Individual survival time varies greatly, but several variables can be used to predict survival and tailor a patient's care plan based on estimated prognosis.

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Outcome of renal replacement therapy in the very elderly

Abstract: Very elderly ESRD patients on RRT have a very poor outcome and, since they are the largest growing group of RRT patients, this has important implications for future health policies.

Cited by 103 publications

References 18 publications

Clinical Practices and Outcomes in Elderly Hemodialysis Patients

Clinical Practices and Outcomes in Elderly Hemodialysis Patients

Fistula First Is Not Always the Best Strategy for the Elderly

Survival after Dialysis Discontinuation and Hospice Enrollment for ESRD

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