The time of initiation of

dialysis in elderly patients

Behzad Einollahi

Professor of Nephrology

Baqiyatallah University of Medical Sciences

Incidence and Prevalence

In the recent years, increased numbers of older

pts have initiated dialysis worldwide in terms of

both absolute numbers and rates per million

population.

Dialysis initiation rates are reported at 1744 per

million population for those aged 75 yr.

USRDS Data Report: Incidence and Prevalence.

• The optimal timing of initiation of dialysis therapy remains an unresolved issue among nephrologists.

• Indications for initiation of dialysis in CKD dialysis involves the consideration of subjective and objective parameters by the physician and the patient.

These parameters are often modulated by the patient's perception of his or her quality of life and by possible anxiety about starting new therapy that is technologically complex.

There are no absolute levels of kidney function that indicate a requirement for dialysis; as such, the decision to initiate dialysis may be a complex one that the physician must make in conjunction with the patient.

The decision to start dialysis is

generally guided by

clinical data such as uremia symptoms, signs of protein–energy wasting or fluid

overload

the measures of renal function, most often eGFR from serum creatinine

Timing of initiation of dialysis among

asymptomatic CKD patients

There is no specific threshold GFR level that has been established for the initiation of dialysis.

However it should be considered in the asymptomatic patient with eGFR 8 to 10 mL/min per 1.73 m2.

Some clinicians may choose to closely monitor (weekly) asymptomatic pts with progressive

CKD even when GFR is below this level, with the initiation of dialysis upon the onset of

uremic signs/symptoms.

Updated guidelines from2006

dialysis should start before CKD stage 5 (GFR <15

mL min )

if pts have symptoms

believed to be elated to a

combination of existing

comorbidities and insufficient renal

function

Does early dialysis or referral improve

survival/outcomes?

Some retrospective and uncontrolled

prospective studies have reported a

benefit associated with early initiation

whereas others have reported

increased mortality.

In recent years, there has been a shift towards

an earlier start in both Europe and the USA.

However, recent observational studies

unable to confirm any benefit of early

dialysis initiation. pts starting the dialysis at a lower eGFR level survived significantly

longer.

a recent meta-analysis that included four randomized controlled trials and 19

observational studies conducted over four decades suggested that early dialysis

initiation may have a beneficial effect on

survival.

In the publication by Stel et al. data from European registries are

presented which show that the lower the eGFR at the start of dialysis, the better the outcome

(in terms of longer survival).

“no benefit from early start of dialysis”

interpretation is that the increased mortality

before and after initiation of dialysis may be a

result of

dialysis-induced silent MI

HD is an independent risk factor for the development of CHF and cardiac death

Problems

Elderly pts who are on dialysis seem to have a

higher burden of age-related problems, or

“geriatric syndromes,” such as frailty, falls, and

cognitive impairment.

There is also emerging evidence that dialysis

initiation may be associated with accelerated

rates of functional and/or cognitive decline.

frailty

The term “frailty” is used to describe

patients with sarcopenia, weakness, weight

loss, and functional decline.

Frail individuals are at high risk for

increased morbidity, hospitalization,

nursing home placement, and mortality.

Fried LP, et al. J Gerontol A Biol Sci Med Sci 56: M146–M156, 2001

frailty

Individuals who were older than 65 yr,

those with impaired renal function were

shown to be at higher risk for frailty than

those with normal renal function (15 versus

6%, respectively)

Shlipak MG, et al. Am J Kidney Dis 43: 861–867, 2004

frailty The data showed an inverse relationship between the

prevalence rates for frailty and the level of renal

function.

Dialysis pts have been shown to experience one of the

highest prevalence rates for frailty.

In the Dialysis Morbidity and Mortality Study (DMMS)

Wave II study, a total of 67.7% of patients of all ages

met collective criteria for frailty.

Johansen KL, et al. J Am Soc Nephrol 18: 2960–2967, 2007

Accidental Falls

Fall incidence rates have been estimated

between 1.2 to 1.6 falls per person-year

for dialysis pts with older than 65 yr.

It is interesting that falls were associated

with a two-fold risk for mortality.

Functional Decline and Disability

Loss of independent functioning and high

levels of dependence have been recognized

in older individuals who are on dialysis.

High dependence has been reported in

elderly prevalent dialysis pts: More than

50% of patients required help with at least

one aspect of personal care.

Cognitive Function

Brain function has been seen to be

affected by the presence of CKD, such

that as kidney disease progresses,

cognitive function declines.

The effect of ESRD on life expectancy

Data from the USRDS indicate that pts

aged 65 or more undergoing dialysis have a

life-expectancy of approximately four

years, which is markedly lower than that of

a patient of the same age without ESRD.

USRDS. Am J Kidney Dis 2006; 47(Suppl 1):S1.

The effect of ESRD on life expectancy

The impact of ESRD on life

expectancy generally decreases

with increasing age.

Balancing Benefit and Burden

The benefit of dialysis is undoubtedly

prolonged survival in those with ESRD.

In Canada, pts who started dialysis when

they were aged 75-80 yr had a 14%

increase in life expectancy (average life

expectancy 3.19 yr vs 2.73 yr).

Jassal SV, et al. CMAJ 177: 1033–1038, 2007

Balancing Benefit and Burden

The prognosis with dialysis

treatment is similar to that of

colorectal cancer and only

marginally better than that of lung

cancer.

Jassal SV, et al. CMAJ 177: 1033–1038, 2007

Balancing Benefit and Burden

Dialysis care offered only marginal benefits

Median survival 8.3 versus 6.3 mo for those

who opted for dialysis care compared with

those who accepted palliative care

recommendations, respectively.

Smith C, et al. Nephron Clin Pract 95: c40–c46, 2003

The final goal is to improve the quality

of life

physical

Mental

Psychosocial

occupational

The effect of ESRD on

quality of life

Despite limited survival for some pts,

many elderly pts have a high quality of

life on dialysis, lending support to the

policy of the continued offering of

ESRD therapy to these pts.

Elderly people form the fastest growing

segment of the dialysis population.

often refer late for dialysis

have several comorbid conditions

are at risk of cognitive dysfunction

declining vision

Nutrition is major problem

undergo dialysis treatment that will

most likely prolong their life

or to decline dialysis which could mean

dying sooner

Challenge for the nephrologist to decide

whether starting dialysis

when there are multiple

comorbidities.

Will dialysis prolong life?

If it does, will it be at the

expense of quality of life?

Poor prognostic factors in this population

Non-ambulatory

statusimpaired

intellectual status

diabetes

low serum albumin

peripheral vascular disease

late referral for ESRD treatment

Older age

Conservative care

Such patients continue to be followed in renal clinics with active management focusing on anemia, fluid status and symptom control.

Nonaggressive Renal Care and

End-of-Life Care

This term is a conservative care.

Providing care at the end of life is

an important aspect of

comprehensive geriatric

nephrology care.

Nonaggressive Renal Care and

End-of-Life Care

Aggressive management of non–renal-

specific symptoms such as pain and

depression are essential, and involvement

of the palliative care service is

recommended.

Discontinuing Dialysis

Withdrawal from dialysis is a common

cause of death among elderly pts with

ESRD.

The rate of voluntary withdrawal from

dialysis increases with age.

Modality Choices

The use of PD in elderly pts may be controversial.

Although the worldwide use of PD has declined,

11.6% of pts aged 75 yr in Canada and 15% of pts

aged 65 yr in the U.K. are started onto PD as their

initial dialysis modality.

2009 UK renal registry: Initial dialysis modality.

2007Annual Report: Treatment of End-Stage Organ Failure in Canada, 1996–2005.

Modality Choices

Reports suggesting that elderly women with

diabetes experience higher mortality when

treated with PD as their initial dialysis modality

are of concern.

The data showing an increased mortality risk

would likely shorten life only by a few weeks to

months in contrast to a potentially improved

quality of life.Vonesh EF, et al. Kidney Int Suppl S3–S11, 2006

Choice of therapy

Compared with younger pts, older individuals

are more likely to initiate renal replacement

therapy with HD.

In one single center study, pts older than 75 years

of age were more frequently treated by HD than

PD (81% vs 19%) when compared to their

younger counterparts (65% vs 35%).

Létourneau I, et al. Renal replacement in end-stage renal disease

patients over 75 years old. Am J Nephrol 2003; 23:71.

Treatment of elderly ESRD pts (>75

yr) In USA

In-center hemodialysis: 96%

Continuous ambulatory peritoneal dialysis

or continuous cycler peritoneal dialysis

(CAPD/CCPD): 3.5%

Home hemodialysis: 0.3%

USRDS. Am J Kidney Dis 2006; 47(Suppl 1):S1.

Mortality rate

Mortality in the first year after the

initiation of dialysis exceeds 35%

among pts older than 70 years of age

and exceeds 50% among pts older than

80 years of age.

Tamura MK, et al. Functional Status of Elderly Adults before and after

Initiation of Dialysis N Engl J Med 2009; 361:1539-1547.

Among nursing home residents

with ESRD, the initiation of

dialysis is associated with a

substantial and sustained decline

in functional status in addition to

very high mortality.

Tamura MK, et al. Functional Status of Elderly Adults before and after

Initiation of Dialysis N Engl J Med 2009; 361:1539-1547.

OUTCOMES OF

HEMODIALYSIS

Despite complex comorbid and

psychosocial conditions, survival

and the quality of life in the elderly

patient on HD is frequently

acceptable.

OUTCOMES OF HEMODIALYSIS

Observational studies have found significantly

improved survival in elderly pts who initiated

dialysis versus those treated conservatively.

An observational single center study of 202

elderly pts with ESRD found higher median

survival among those who underwent dialysis

versus pts treated conservatively (38 vs 14

months, respectively).

Carson RC,et al. Clin J Am Soc Nephrol 2009; 4:1611.

OUTCOMES OF HEMODIALYSIS

An acceptable subjective quality of

life and degree of rehabilitation

have also been noted in many other

reports.

Panarello G, et al. Adv Perit Dial 1989; 5:49.

OUTCOMES OF HEMODIALYSIS

One study of 3701 nursing home residents who

initiated dialysis found that, one year after

dialysis was begun, nearly 60% had died and

only 13% had maintained their predialysis

functional status.

Thus, frail elderly nursing home residents

perform relatively poorly with maintenance

dialysis, particularly if effective rehabilitation is

not performed.

Outcomes among the very old

In one study from the USRDS, the one-year

mortality of pts aged 80 and older was 46%,

which had not changed in the period from 1996

to 2003.

Independent predictors of poor survival among

the very old include older age, poor nutritional

status, nonambulatory status, late referral for

dialysis initiation, and the presence of significant

comorbid conditions, particularly cardiovascular

diseaseKurella M, et al. Ann Intern Med 2007; 146:177.

Malnutrition

The incidence of malnutrition among

dialysis pts may be higher among the

elderly than younger pts.

Malnutrition among all dialysis pts,

including the elderly, is associated with

decreased survival.

Infection

The elderly are at an increased risk for

infections due in part to aging of the

immune system and the effect of poor

nutrition on overall immune function.

Such infections result in significant

morbidity and mortality among these pts.

Gastrointestinal Bleeding

Elderly pts have an increased incidence

of diverticulosis, angiodysplasia, and

carcinoma.

These lesions can contribute to a

higher incidence of GI bleeding when

on dialysis.

SUMMARY AND

RECOMMENDATIONSDespite limited survival for some pts, many

elderly pts have a high quality of life on

dialysis, lending support to the policy of the

continued offering of ESRD therapy to

these pts.

Most elderly pts would also choose dialysis

therapy if given the therapeutic option,

particularly if symptoms were relieved and

independence was maintained.

SUMMARY AND

RECOMMENDATIONS

Dialysis should therefore not be denied to

elderly pts, even the very old, if there is

hope for prolongation of an enjoyable span

of life.

When there is doubt about chances of

recovery from a severe underlying disease,

a "trial" of dialysis may be offered.

SUMMARY AND

RECOMMENDATIONSWithdrawal of dialysis at a later time is

preferable to withholding it from the

beginning.

The major contraindications to dialysis

are advanced malignancy (with the

possible exception of multiple

myeloma) or irreversible dementia or

advanced liver disease.

dialysis start should be based

on clinical factors rather than

numerical criteria such as the eGFR

alone

Thanks you all for your attention