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*Division of Nephrology, University of Toronto, Toronto, Ontario, Canada; and Center for Renal Diseases, Zvezdara University Hospital, Belgrade, Yugoslavia.
Correspondence to Dr. Dimitrios Oreopoulos, Toronto Western Hospital, 399 Bathurst St., Toronto, Ontario, M5T 2S8 Canada. Phone: 416-603-7974; Fax: 416-603-8127; E-mail: dgo{at}teleglobal.ca
Contrary to predictions in the Gottschalk report to the US Congress in 1960 that the projected incidence of new end-stage renal disease patients will be on the order of 20 new patients per year, this number has been exceeded tenfold, mainly because no one anticipated the increase of elderly patients being accepted for dialysis. According to the US Renal Data System 2000 Annual Data Report, the mean age at the initiation of dialysis was 61 yr, and the fastest-growing group was patients 75 yr of age and older (1). Similar findings have been reported from other Western countries (2,3 ). These data suggest that ESRD has become a geriatric illness and that, in the 21st century, nephrologists will be forced to practice mainly geriatric medicine as amateur geriatricians, having only limited knowledge of the special challenges posed by the elderly.
To provide appropriate care to these patients, one should keep in mind that they face not only medical but also social problems. These include accurate diagnosis and on-time referral, multiple comorbidity, optimal mode of therapy, quality of life, and ethical and social issues. In this context, the study of Jolly et al. (4), reported in this issue of JASN, is welcome because it highlights one important and sensitive issue: that of offering or withholding dialysis from octogenarians with ESRD and the consequences of such a decision. The authors present a single-center cohort of 146 octogenarians referred over a 12-yr period and, for the first time in the literature, compare the results of actively treated patients with those from whom dialysis was withheld and who were managed conservatively. Dialysis was withheld from 29% of patients. The decision to withhold was made mainly by the nephrology team in 86% of patients; in only 14% was the decision made by the patient himself or herself. The presence of low Karnofsky scores (KS), social isolation, and late referral were the most important factors that influenced the nephrology team’s decision to propose conservative treatment. Median survival of dialyzed patients was 28.9 mo, which is one quarter to one third of their normal life expectancy at that age. Not surprisingly, survival of dialyzed patients was significantly higher than that of non-dialyzed (8.9 mo). One-year mortality was predicted by three significant covariates (body mass index [BMI], referral time, and Karnofsky score [functional dependence]) and was 15% in the low-risk group (early referred, BMI = 22, KS > 40) and 83% in the high-risk group (late referred, BMI = 18, KS < 40).
These investigators have provided us with some valuable information: (1) one can observe excellent results if octogenarians are accepted for dialysis; (2) conservative treatment yields poor results; (3) there are identifiable factors influencing the decision-making process; and (4) some of the independent risk factors that predict outcome may be modifiable. Now one can use their outcome findings (a and b) whenever one is discussing dialysis options with octogenarian patients with ESRD.
Early referral was associated with higher acceptance into the dialysis program and a better prognosis. It has been recognized before that early mortality (first 90 d) is high among the elderly ESRD population (27% for those over 85 yr) and that late referral to nephrology units is significantly related to early death (5), longer initial hospitalization, and greater frequency and longer duration of subsequent hospital admissions (6,7 ). It should be noted, however, that it is often not that the elderly are not referred early but that the nephrologists may delay the initiation of dialysis because of misleading serum creatinine levels. Therefore, NKF-DOQI guidelines recommend that one use calculated weekly creatinine clearance when making decisions about the initiation of dialysis (8). Furthermore, one should consider initiation of dialysis before uremic symptoms become overt and malnutrition evident (9). Unfortunately, some primary-care physicians still use age as a criterion for referring these patients to the nephrologist for dialysis. A recent study showed that only 65% of US and Canadian physicians and an even lower percentage (49%) of British physicians would refer elderly patients to a nephrologist for dialysis irrespective of age (10).
Another important issue is the decision-making process for offering or withholding dialysis after the attending physician has decided on referral to a nephrologist. Healthcare professionals cannot make this decision for others; instead, they should advise patients, sharing with them their knowledge and experience without projecting their own prejudices. Joly et al. clearly show the consequence of withholding dialysis and emphasize the need for guidelines when discussing dialysis options with such patients. Fortunately, the American Society of Nephrology and the Renal Physicians Association published evidence-based guidelines in 2000 (11), which emphasize that only informed patients or their surrogates should make the final decisions (12). If a conflict exists between provider and patient/family, the provider should fall back on established ways of conflict resolution rather than imposing arbitrary decisions and confrontation. It sometimes takes a long time to come to a satisfactory decision for the patient/family, but it is time well spent. Guidelines recommend against offering dialysis to patients with a known and advanced terminal illness or those who have serious mental impairments as a results of stroke, Alzheimer disease, or neurologic dysfunction. When neither the medical team nor the patient or family member can decide whether or not to dialyze, the patient should be offered a trial period of dialysis of 30 to 90 d.
Another important point regarding the factors that influence decision-making about dialysis is that some of these factors may be reversible. Joly et al., who used the Karnofsky scale (physical dependency) to measure activity level, show that a low score is a poor predictor of outcome. Although quality of life does not always depend on the patient’s physical state, these findings emphasize the importance of physical activity, which may be improved by control of anemia with EPO and specially designed rehabilitation programs either before or during dialysis (13). Social isolation was also a significant predictor for withholding dialysis. Better social support is of great importance to the increasing number of elderly who need assisted care. Even the most complicated cases, i.e., those with mental and physical disability and without family support, should not be automatically refused treatment; with a broad network of medical and social support, home-care nursing, and rehabilitation programs, these patients can improve and take on the burden of dialysis if they so desire. Alternatively, dialysis can be provided in a long-term care facility (14).
There are many unanswered questions about the management of elderly with ESRD, such as optimal mode of therapy, modality-related complications, quality of life, and survival on various dialysis modalities. The answers to all of these require well-designed, prospective studies on large series of patients. For us, the most important is whether dialysis is worth starting in the elderly, particularly in octogenarians. Joly et al. have confirmed that survival of those treated with dialysis is satisfactory and is significantly better than in those treated conservatively. These findings should be presented to all those caring for such patients, especially to the primary-care physician but also to the public at large. It is now clear that octogenarians can be effectively treated by dialysis.
No one can discuss dialysis in the elderly without considering the financial implications of such a decision. As Joly et al. say, no one has imposed explicit restrictions on the provisions of dialysis to those in need irrespective of age, nor do such restrictions exist in the United States or any other developed country. Governments usually avoid such explicit orders, especially now that the elderly have become a political force; instead, they impose restrictions by covert means, such as restricting the use of dialysis stations or nephrology positions, or reducing reimbursement or including dialysis costs in the global budget of the hospitals, and so on. Governments also restrict access by emphasizing the social responsibilities of the physicians vis à vis their responsibility to the patient, expecting them to look at the bottom line, thus making them gatekeepers. Because they cannot do it openly, physicians who respond to such pressures may say that dialysis in the elderly is futile. This in reality is rationing. We believe that physicians have a primary responsibility to their patients and should never betray their trust. Under the present climate of cost consciousness, physicians in general and nephrologists in particular should speak up and advocate for their elderly patients, because no one else will do it for them.
We believe that the publication of the article by Joly et al. will stimulate further discussion about the needs and rights of the elderly with end-stage renal disease and that geriatric nephrology will be taken more seriously in the future. We hope that the 7th International Conference on Geriatric Nephrology that will take place in Atlanta, GA, October 9–12, will be able to establish the subspecialty of Geriatric Nephrology to serve the increased number of elderly patients with ESRD who need our care.
Note:For more information on the 7th International Conference on Geriatric Nephrology, contact Dr. Nancy Kutner at nkutner@emory.edu.
References
This article has been cited by other articles:
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  C. Fourtounas, A. Hardalias, P. Dousdampanis, E. Savidaki, and J. G. Vlachojannis Intermittent peritoneal dialysis (IPD): an old but still effective modality for severely disabled ESRD patients Nephrol. Dial. Transplant., October 1, 2009; 24(10): 3215 - 3218. [Abstract] [Full Text] [PDF]
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 S. Taneja, S. Mandayam, Z. Z. Kayani, Y.-F. Kuo, and V. B. Shahinian Comparison of Stage at Diagnosis of Cancer in Patients Who Are on Dialysis versus the General Population Clin. J. Am. Soc. Nephrol., September 1, 2007; 2(5): 1008 - 1013. [Abstract] [Full Text] [PDF]
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N. C. Reddy, S. M. Korbet, J. A. Wozniak, S. L. Floramo, and E. J. Lewis Staff-assisted nursing home haemodialysis: patient characteristics and outcomes Nephrol. Dial. Transplant., May 1, 2007; 22(5): 1399 - 1406. [Abstract] [Full Text] [PDF]
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