Calculate benefit before dialysis for frail elders

BOSTON — Kidney specialists should weigh the potential quality of life for frail elders with end-stage renal disease (ESRD) in opting for dialysis over more conservative therapies, a nephrologist and a palliative care specialist suggest in an editorial in the New England Journal of Medicine.

Acknowledging a lack of data from randomized trials evaluating the benefit of dialysis in the elderly, authors Mark L. Zeidel MD, and Robert M. Arnold MD, believe that “to care effectively for these persons, we must now learn much more — we must define who among this population will benefit most from dialysis and who will benefit most from conservative therapy.”

Zeidel is a nephrologist, Chairman of the Department of Medicine at Beth Israel Deaconess Medical Center and a Professor of Medicine at Harvard Medical School. Arnold is the Director of the Palliative Care Service at the University of Pittsburgh Medical Center and Dr. Leo H. Criep Chair in Patient Care and Professor of Medicine at the University of Pittsburgh School of Medicine.

The editorial accompanies a NEJM study on outcomes involving all nursing home residents in the United States who began to undergo dialysis between June 1998 and October 2000 and for whom predialysis status was available. The study found poor overall outcomes, in the first year after initiation of dialysis with 58 percent of residents dying and 29 percent having a decrease in functional status. Only 13 percent maintained functional status.

Dialysis provides artificial replacement of lost kidney function, passing a patient’s blood through a machine that filters out impurities normally captured in the organ. The treatment can be lengthy and physically challenging for patients.

Conservative treatment, which does not involve dialysis, focus on medicines to decrease the symptoms of the kidney failure places less physical stress on patients and can result in a better quality of life, particularly for patients in ESRD. This care draws on knowledge in nephrology, geriatrics and palliative care.

Zeidel and Arnold note that small studies that examine the outcome of patients who elect conservative therapy over dialysis suggest that mortality and quality-of-life outcomes do not differ very much among selected patients who undergo dialysis and those who do not. They believe it is critical that larger studies be designed to determine the actual benefit of dialysis for frail elders.

In the meantime, “optimal care requires clear, informed conversations about the patient’s goals, given his or her disease and the ability of various treatments to achieve these goals.

“Conservative therapy should be discussed, not as a last resort where there is ‘nothing left to do’ but as a clear option that might be most effective in promoting patient goals.”

The authors also believe nephrologists need to become more aware of national guidelines on shared decision making regarding the initiation and withdrawal of dialysis, citing the fact that 30 percent of the patients older than 75 withdraw from dialysis indicate “the ability to counsel patients about potentially foregoing dialysis should be a core competency for nephrologists.”

Arnold and Zeidel note than elderly patients with ESRD have multiple functional impairments, physical symptoms and a high rate of depression, facts that require an integrated, holistic approach to the care. There are also increased rates of frailty, cognitive dysfunction and geriatric syndromes such as falls and hospitalization involving elders undergoing dialysis.

Despite the fact that palliative care consultations for patients with cancer have shown decreases in symptoms and improved satisfaction, the authors note ESRD patients are less likely to receive comprehensive palliative care consultations. They recommend routine inclusion of palliative care specialists for these patients.

“In persons who will benefit, we must determine when we should initiate dialysis; this may differ substantially from initiation of dialysis in younger, healthier patients with ESRD,” they note. “We must learn much more about how to ensure that we obtain truly informed consent from our patients, how to support them optimally in their therapeutic decisions and how to relieve their symptoms most effectively.

No potential conflicts of interest relevant to this article were reported.

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and consistently ranks among the top four in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit www.bidmc.org .

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