A new study recently published in Annals of Internal Medicine by lead author Maria Montez Rath, senior author Manjula Tamura (both Stanford University School of Medicine, Palo Alto, USA) et al suggests that there is more consideration needed regarding the suitability of dialysis for older adults with kidney failure.
The main purpose of the study was to quantify what dialysis entails for older adults who are ineligible for a transplant: whether and how much it prolongs life, along with the relative number of days spent in an inpatient facility such as a hospital, nursing home or rehabilitation centre.
In order to do so, the authors of the study evaluated health records from between 2010–2018 of 20,440 patients (98% male) from the US Department of Veterans Affairs. In order to be included in the study, the patients had to be over 65 years old, had chronic kidney failure, were not undergoing evaluation for transplant and had an eGFR below 12mL/min/1.73m2.
Conducting a retrospective randomised clinical trial based on the health records of these patients, the researchers split the patients into two groups—those who waited at least a month to begin dialysis and those who started immediately—and found that, in the group of patients that waited, roughly half never started dialysis at all.
They also found that patients who started dialysis immediately lived on average nine days longer than those who waited, but they spent 13 more in an inpatient facility. They also found that age had a significant impact on outcomes; patients aged 65–79 who started dialysis immediately on average lived 17 fewer days and also spent 14 more days in an inpatient facility, whereas patients 80 years old and older who started dialysis immediately on average lived 60 more days, but spent 13 more days in an inpatient facility.
Contrastingly, patients who never received dialysis treatment died an average of 77 days earlier than patients who started it immediately, but they spent 14 more days at home.
In a recent press release from Stanford Medicine, Tamura noted that physicians sometimes recommend dialysis because, as she said, “they want to offer patients hope or because the downsides of the treatment haven’t always been clear”. Despite this, she argued that their study indicates that physicians and patients may want to wait until the eGFR drops further and “should consider symptoms along with personal preferences before starting dialysis”.
“Different patients will have different goals,” she said. “For some it’s a blessing to have this option of dialysis, and for others it might be a burden.” She added that “it may be helpful if clinicians portray dialysis for frail, older adults as a palliative treatment—primarily intended to alleviate symptoms”.
One of the reasons that patients so frequently opt for dialysis as their form of treatment, Montez Rath shared, is that they believe it is the only option that is available to them or that it has the best outcomes in terms of prolonging or extending their life. “They often say yes to dialysis, without really understanding what that means.”
The main takeaway from this study that Montez Rath and Tamura feel is key is that more consideration needs to be given to alternatives to dialysis, particularly for the elderly. Medications can be taken in lieu of dialysis to manage symptoms of kidney failure—such as fluid retention, itchiness and nausea. These are also free from some of the side effects of dialysis, such as cramping and fatigue, and the “major lifestyle change” that is required to undergo an intensive therapy such as dialysis.
“For all patients, but particularly for older adults, understanding the trade-offs is really essential,” Tamura said. “They and their physicians should carefully consider whether and when to proceed with dialysis.”
“The study shows us that if you start dialysis right away, you might survive longer, but you’re going to be spending a lot of time on dialysis, and you’re more likely to need hospitalisation,” Montez Rath said.
“Currently, dialysis is often framed to patients as a choice between life and death,” she said. “When it’s presented in this way, patients don’t have room to consider whether the treatment aligns with their goals, and they tend to overestimate the benefits and well-being they might experience. But when treatment is framed as symptom-alleviating, patients can more readily understand that there are trade-offs.”
