The management of uraemia in the elderly: treatment choices

Chronic Peritoneal Dialysis in the Elderly: A Review

During the past few decades, the pattern of end-stage renal disease has changed significantly with the emerging predominance of elderly patients. Because this heterogeneous population is characterized by a physiological decline in function of all organs, the nephrologist must contemplate the special needs of individual patients when they develop end-stage renal disease. Before the initiation of dialysis, these patients must be given detailed information to help them select the particular mode that will maximize their quality of life. According to available data, peritoneal dialysis offers some advantages for elderly patients, such as hemodynamic stability, steady-state metabolic control, good control of hypertension, independence from hospital, and avoidance of repeated vascular access. Early referral promotes the establishment of peritoneal access and minimizes the consequences of uremia, subsequent morbidity, and frequent hospitalization. Elderly patients are compliant and highly motivated to cooperate with their treatment. They have no higher modality-related complications than younger patients and their quality of life is satisfactory. Although most have comorbid conditions that interfere with self-performance of dialysis, such as impaired vision and reduced physical and mental activity, they can perform peritoneal dialysis successfully if they have a high level of family support. Patients who do not have family support may have successful peritoneal dialysis if they have access to a network of medical and social support, that is, private home nurses, rehabilitation and chronic care dialysis units, or nursing homes.

Quality of Life of Patients with Advanced Chronic Kidney Disease Receiving Conservative Care without Dialysis

With the evidence that dialysis may not necessarily be beneficial for older adults with advanced chronic kidney disease (CKD), there is a growing interest in promoting conservative care without dialysis as a viable treatment option for these individuals. This review summarizes the current empirical evidence of symptom experiences and quality of life of patients receiving conservative care. Data suggest that conservative care may yield symptom experiences and quality of life that are compatible with those of patients on dialysis. However, these data are exclusively from studies conducted outside of the United States in which there were often no comparison groups or study designs that could provide high quality evidence. There is an urgent need for further research and developing a conservative care model suitable for CKD populations in the U.S.

End-Stage Renal Disease and Renal Replacement Therapy in older Patients

As the world’s population continues to age, practitioners encounter increasing numbers of older patients with end-stage renal disease (ESRD) who require renal replacement therapy (RRT). Conservative management may be considered in older patients and has been shown to offer comparable survival rates and hospital-free days to RRT patients. At present, for those who choose RRT, hemodialysis is the most commonly used modality. Many practitioners believe that peritoneal dialysis (PD), including assisted peritoneal dialysis, can be used safely in this population. Age is not a contra-indication to peritoneal dialysis, and a choice of modality should be offered to older patients. Assisted peritoneal dialysis has been used successfully in multiple regions without an increase in complication rates. Quality of life is an important issue for older patients with ESRD, and studies such as Broadening options for long-term Dialysis in the Elderly support the use of PD in older patients as it is associated with fewer fluctuations in symptoms of ESRD and less intrusion into people’s lives. This review discusses the appropriateness of initiating RRT in older patients, choices of modality, underutilization of PD in older patients, use of assisted PD, complication rates, and quality of life in these patients. overall, PD seems to be a safe and effective modality of RRT in older patients, and assisted PD can be used in patients with limited functional impairment.

Dialysis in the elderly

More and more elderly (>65 years) patients are now reaching end-stage renal disease (ESRD) due to better management of co-morbid diseases. There are complex medical issues that need to be addressed when managing ESRD in this patient group. The option of dialysis in the elderly is a viable one. However, it needs careful consideration of patients' choices besides coexisting illnesses. Ideally, dialysis should prolong survival. However, an equally important issue is quality of life on dialysis. Life should be added to years and not years added to life. This often involves multidisciplinary input from various disciplines involved in patient care. Other than life on dialysis, the only other alternative is conservative management. Conservative management is not 'passive palliative therapy'. Rather, it involves active management of various clinical issues in a sick and vulnerable patient who does not have age on his side. All elderly patients have unique issues and no generalizations can be made. However, careful analysis makes it possible to offer dialysis to the right patient in the elderly and very elderly (>75 years and beyond) subgroups.

Clinical spectrum of chronic renal failure in the elderly: a hospital based study from eastern India

The aim of this study was to describe the clinical spectrum of chronic renal failure (CRF) in the elderly. The diagnosis of CRF was made using standard clinical criteria. The elderly was defined as person with over 60 years of age. In total, 200 elderly patients with CRF were evaluated between July 2002 and February 2004. Their age (male: 146; female: 54) ranged between 60 and 90 (mean 64.31+/-4.18) years. Diabetic nephropathy was the most common (46%) cause of CRF. Hypertensive nephrosclerosis, chronic interstitial nephritis and obstructive uropathy were responsible for CRF in 18%, 14% and 13% of patients, respectively. We observed chronic glomerulonephritis in 7% of elderly CRF. Urinary tract infection (55.5%), hypovolemia (22.2%), accelerated hypertension (11.1%) and sepsis (11.1%) were responsible for acute exacerbation of renal failure in 36 (18%) patients. Associated co-morbid conditions were noted in 93 (46.5%) patients. They included; coronary artery disease 46 (49.46%), cerebrovascular disease 20 (21.50%), osteoarthritis 13 (13.97%), chronic obstructive pulmonary disease 6 (6.45%), dilated cardiomyopathy 5 (5.37%), and malignancy in 3 (3.22%) patients. Acute dialytic support was required in 164 (82%) cases and remaining 36 (18%) patients received conservative management. Mortality was noted in 25 (12.5%) cases. The coronary artery disease (48%), acute pulmonary edema (20%) and hyperkalemia (12%) were the main causes of death. Subsequent evaluation revealed that 102 (51%) patients had ESRD of which only 3 (2.94%) patients could afford CAPD. A total of 11 (10.7%) patients underwent chronic maintenance hemodialysis for 3-4 months and then discontinue dialysis mainly because of financial constraints. Remaining 88 (86.27 %) patients with ESRD were discharged from hospital after symptomatic improvement with acute dialysis. Thus, diabetic nephropathy related to type-2 diabetes was the commonest cause of CRF in our elderly patients. Chronic renal failure in elderly was associated with a number of co-morbid conditions, which contributed significantly to morbidity and mortality. Acute on chronic renal failure with severe uremic complications were an important cause of hospitalization. The financial constraint was the major limiting factor for the management of elderly ESRD patients.

Discontinuation of dialysis treatment: experience of a single dialysis centre

OBJECTIVE

Discontinuation of dialysis is a common cause of death in end-stage renal disease (ESRD) patients in the USA and UK, but is less common in the rest of Europe and in Japan. The aim of this study was to describe the discontinuation pattern in a single dialysis unit in eastern Finland.

MATERIAL AND METHODS

We retrospectively analysed the case history and cause of death of 146 dialysis patients in whom dialysis treatment was started between 1992 and 2001 and who had died by March 2003. We compared patients who died after withdrawal from dialysis and those who continued dialysis until death.

RESULTS

In 53 patients (36.3%) dialysis treatment was discontinued before death (withdrawal group). In the rest of the patients (control group; n=93) dialysis was continued until death. The patients in the withdrawal group were older (median 69 vs 65 years at the onset of ESRD), more often institutionalized before death (49% vs 11.8%) and more often had dementia diagnosed before death (20.8% vs 2.2%) than those in the control group. They were also less rehabilitated before death (54.7% vs 76.7%) and their treatment more often lasted for <3 months (20.8% vs 7.6%). The patients in the withdrawal group died less often of cardiac disease (11.3% vs 39.8%), whereas kidney disease was the commonest cause of death (41.5 vs 19.4%). The commonest reason for discontinuation of dialysis was severe medical illness (86.5%). In most cases the nephrologist or the renal team raised the issue of stopping dialysis. Nearly 70% of patients were incompetent at the time of the decision. Patient refusal to stop dialysis was uncommon.

CONCLUSIONS

Stopping dialysis before death is a common practice in our unit. Dialysis was mostly discontinued in severely ill patients who were near the end of their life. The nephrologist or the renal team decided to stop treatment. Our results should encourage renal teams to raise the issue of stopping dialysis when a patient's illness has become terminal. More studies and discussion of this difficult field are needed.

Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France

BACKGROUND

In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. The aim of this study was to analyse the practices of some French nephrologists, 17 of whom (in six nephrology units) were interviewed for this study.

METHODS

A questionnaire was formulated on the basis of a bibliographical search of the topic. A series of questions, initially open and then more targeted, regarding scientific and non-scientific factors influencing the decision to discontinue or refuse haemodialysis in elderly patients, were put to nephrologists.

RESULTS

Psychological and physical deterioration emerged as the principal factors governing decisions to refuse or discontinue treatment. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. Although the main reasons for refusing dialysis were cognitive disorders, severe dementia and irreversible neurological conditions, none of these factors where actually found to be in and of themselves decisive.

CONCLUSIONS

This study has shown that refusing or discontinuing dialysis are practices accepted by the vast majority of nephrologists in one region of France. Patient refusal is not a basis for denial or discontinuation of dialysis in elderly patients. Our investigation has demonstrated a consensus regarding decisions to refuse or discontinue dialysis.

Chronic peritoneal dialysis in octogenarians

BACKGROUND

During the past few decades the pattern of end-stage renal failure disease has changed with increasing number of elderly patients admitted for dialysis. In spite of their increasing number, little is known about the optimal mode of therapy of the 'old old' (those >or=80 years) patients.

METHODS

In this retrospective study, we analysed the results of treatment of 31 non-institutionalized 'old old' patients at Toronto Western Hospital (17) and Scarborough General Hospital (14) and seven institutionalized patients in chronic care, Riverdale Hospital. The patients were on CAPD with Twin-bag Baxter (28) or Home Choice, Baxter or Fresenius CCPD system (10). Patients were screened at the CAPD clinic when routine blood investigations were done. Patient and technique survival, initial and final laboratory data (last visit or before death) and complications related/unrelated to dialysis method are presented.

RESULTS

Multiple comorbid conditions were present at the start of the treatment and new added during treatment; very few were dialysis-related. The majority of non-institutionalized patients required assistance of home-care nurse to perform dialysis. Peritonitis (1/28.6 patient months) and exit-site infection rate (1/75.1 patient months) were low and responded to treatment. Incidence of peritonitis was higher among institutionalized debilitated patients (1/5.3 patient months). Incidence of hospitalization was 1/14.7 patient months and patients spent in hospital 7.5 days/patient year. Forty-seven per cent of patients survived 24 months; 39% survived 30 months. Technique survival was 91.5% at 12 months and 81.4% at 30 months. Poor appetite and malnutrition were frequent among very old patients. Patients and their families were motivated for treatment and discontinuation of dialysis was not higher than described elsewhere in literature.

CONCLUSIONS

This study has demonstrated that chronic peritoneal dialysis could be recommended as a safe and suitable modality of treatment of end-stage renal failure in old old patients.

Renal function and renal disease in the elderly: Part II

In all industrialized countries, life expectancy has risen in the past 100 years. The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renal replacement therapy has also increased. During the past few decades, the pattern of ESRD has changed significantly with the emerging predominance of elderly patients. The causes of this phenomenon are manifold and include an increasing number of chronic diseases typical of the 'third age', such as type 2 diabetes mellitus and vascular disease. In many species, a consequence of aging includes deterioration of renal function, partly due to structural alterations, and partly as the result of a diminishing blood flow. In humans, the aging kidney is characterized by modifications resulting from organic and functional disturbances. In particular, type 2 diabetes mellitus has emerged as an important condition, the microvascular and macrovascular complications of which are a common cause of morbidity and mortality in older patients. In Part II of this review, the specific aspects of renal replacement therapy in the elderly will be discussed.

Outcome of renal replacement therapy in the very elderly

BACKGROUND

In a retrospective case-note and computer database analysis we assessed the outcome of very elderly patients (> or = 75 years old) with end-stage renal disease (ESRD) on renal replacement therapy (RRT).

METHODS

Fifty-eight individuals aged 75 or over (group 1) commenced RRT between 1 January 1991 and 31 December 1995. Comparisons were made with other patients commencing RRT who were divided into two groups: group 2 (201 individuals 65-74 years old) and group 3 (379 patients <65 years old). All subjects were followed up until the point of assessment (30 June 1998), the time of death, or withdrawal from dialysis. Survival rates in the three groups were compared using Kaplan-Meier method. The number of hospital admissions, length of in-patient stay, and complications rate on RRT were assessed for group 1.

RESULTS

One-year survival rates in groups 1, 2 and 3 were 53.5, 72.6, and 90.6% respectively and the 5-year survival rates were 2.4, 18.8, and 61.4% respectively. The very elderly spent 20% of their time in hospital, 46% had two co-morbid factors at the outset, and 26% developed multiple complications while on RRT. Withdrawal from dialysis remained the most common cause of death in this group of individuals (38%), followed by cardiovascular causes (24%) and infections (22%).

CONCLUSION

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.