Improving survival of octogenarian patients selected for haemodialysis

Suboptimal initiation predicts short-term prognosis and vulnerability among very elderly patients who start haemodialysis

AIM

A recent, growing concern regarding haemodialysis in Japan is a sustained increase in the elderly population. Among very elderly people who start haemodialysis, the prognosis is considered to be poor; however, this has not been fully elucidated. This study aimed to discover the short-term prognosis and related factors in very elderly patients who commence haemodialysis.

METHODS

Between January 2008 and December 2013, 122 patients aged ≥85 years at haemodialysis initiation were documented in our hospital. Predictors of 90-day and 1-year mortality after haemodialysis initiation were assessed with Cox proportional hazards regression analysis. Selection of covariates for the multivariate model was based on forward stepwise selection using the probability of a likelihood ratio statistics.

RESULTS

The subjects' mean age was 87.4 ± 2.5 years, and 48% were female. The most common cause of death was infection (38% of patients) and the leading cause of infectious death was pneumonia. The 90-day and 1-year survival rates were 81% and 62%, respectively. Suboptimal initiation was a significant prognostic factor for 90-day [hazard ratio (HR) 3.98, 95% confidence interval (CI) 1.18-13.43] and 1-year [HR 3.19, 95% CI 1.51-6.76] mortality after adjusting for confounders in multivariate analysis.

CONCLUSION

Very elderly patients who started haemodialysis had a poor prognosis, and suboptimal initiation significantly predicted outcome. Shared decision-making with patients and their families is needed for initiating haemodialysis on the conditions that appropriate information on the expected prognosis is provided.

Factors Associated With Withdrawal From Dialysis Therapy in Incident Hemodialysis Patients Aged 80 Years or Older

OBJECTIVES

Among kidney disease patients ≥80 years progressing to end-stage renal disease, there is growing interest in conservative nondialytic management approaches. However, among those who have initiated hemodialysis, little is known about the impact of withdrawal from dialysis on mortality, nor the patient characteristics associated with withdrawal from dialysis.

STUDY DESIGN

Historical cohort study.

SETTING AND PARTICIPANTS

We examined 133,162 incident hemodialysis patients receiving care within a large national dialysis organization from 2007 to 2011.

MEASURES

We identified patients who withdrew from dialysis, either as a listed cause of death or censor reason. Incidence rates and subdistribution hazard ratios for withdrawal from dialysis as well as 4 other censoring reasons were examined across age groups. In addition, demographic and clinical characteristics associated with withdrawal from dialysis therapy among patients ≥80 years old was assessed using logistic regression analysis.

RESULTS

Among 17,296 patients aged ≥80 years, 10% of patients withdrew from dialysis. Duration from the last hemodialysis treatment to death was 10 [interquartile range 6-16] days in patients with available data. Withdrawal from dialysis was the second and third most common cause of death among patients aged ≥80 years and <80 years, respectively. Among patients ≥80 years, minorities were much less likely than non-Hispanic whites to stop dialysis. Other factors associated with higher odds of dialysis withdrawal included having a central venous catheter compared to an arteriovenous fistula at dialysis start, dementia, living in mid-west regions, and less favorable markers associated with malnutrition-inflammation-cachexia syndrome such as higher white blood cell counts and lower body mass index, albumin, and normalized protein catabolic rate.

CONCLUSION/IMPLICATIONS

Among very-elderly incident hemodialysis patients, dialysis therapy withdrawal exhibits wide variations across age, race and ethnicity, regions, cognitive status, dialysis vascular access, and nutritional status. Further studies examining implications of withdrawal from dialysis in older patients are warranted.

A Review of Arteriovenous Fistulae Creation in Octogenarians

BACKGROUND

To analyze the outcomes of arteriovenous fistulae (AVFs) creation in octogenarians.

METHODS

A retrospective study of 47 AVFs created in patients aged 80 years and above from 2008 to 2014. Patient and AVF characteristics and outcomes were evaluated. Predictors of patency were analyzed with multivariate analysis and Kaplan-Meier patency, and survival analysis was performed.

RESULTS

Forty-seven of 1,259 AVFs created were for octogenarians (4%). Mean age was 83 years old (range: 80-91 years), with 27 male (57%) and 35 with tunneled dialysis catheters in situ (75%). There were a total of 15 (32%) radiocephalic AVFs, 30 (64%) brachial-cephalic AVFs, and 2 (4%) brachial-basilic transposition AVFs. At 12 months, assisted primary patency rate was 28% (13 patients) while primary failure rate was 72% (34 patients). Subset analysis showed brachial-cephalic AVFs to have the highest assisted primary patency rate at 33%. Within 24 months, tunneled dialysis catheter-related sepsis rate was 31% (11 patients). Multivariate analysis did not reveal any factor to be statistically significant in predicting AVF patency. Kaplan-Meier survival curve showed a 50% survival rate at 63 months after AVF creation.

CONCLUSIONS

In view of high AVF primary failure rate and relatively low tunneled dialysis catheter bacteremia rate, long-term tunneled dialysis catheters as the main form of hemodialysis renal access may be a viable option. However, with 50% of end-stage renal failure patients surviving up to 63 months after AVF creation, the risks and benefits of long-term tunneled dialysis catheters must be balanced against those of AVF creation.

The very old on hemodialysis: 8 years' experience in a single unit

BACKGROUND

Elderly patients constitute a significant proportion of chronically dialyzed patients. This study evaluated mortality rates and predictors of mortality among very old patients receiving chronic hemodialysis (HDx).

METHODS

A single-center retrospective analysis was carried out on patients >84 years of age who started chronic dialysis between 2004 and 2012. Univariate and multivariate analyses determined which parameters predicted survival.

RESULTS

Twenty-nine hemodialyzed patients (19 males) were studied. Mean age was 88 ± 3 years. Median survival time was 38 months (range 4-96). One-year and 2-year survival probability was 80 and 65%, respectively. The most common cause of death was complicated peripheral vascular disease. Multivariate analysis revealed the following: for each 1 g/dl decrease in serum albumin level, the hazard ratio for patient death was 2.63 (p = 0.017), and for each weekly HDx treatment time decrease of 1 h, the hazard ratio for patient death was 1.40 (p = 0.006).

CONCLUSION

Very elderly patients can be hemodialyzed with cautious optimism.

Prognosis of elderly Japanese patients aged ≥80 years undergoing hemodialysis

Although the number of elderly patients requiring dialysis has increased, data regarding the prognosis of elderly patients undergoing hemodialysis are limited. In the present study, prognosis in Japanese hemodialysis patients aged ≥80 years was evaluated. From January 1988 to July 2013, 1144 consecutive patients with end-stage renal disease required renal replacement therapy at our institution; of these, 141 were aged ≥80 years. These patients' charts were retrospectively reviewed for relevant clinical variables and survival time. The life expectancies table from the National Vital Statistics database was used, and prognostic factors were assessed by multivariate analysis. In total, 107 deaths (76%) were recorded during the study period. The median survival time and estimated life-shortening period in the patients were 2.6 years and -5.3 years, respectively. Eastern Cooperative Oncology Group Performance Status and hemoglobin level were revealed as prognostic factors in the multivariate analysis. Estimates of prognosis and prognostic factors may provide useful information for physicians as well as elderly patients with end-stage kidney disease.

Creation of arteriovenous fistulae for hemodialysis in octogenarians

Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006-2012, 39 patients aged 85.9 ± 2.05 with end-stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety-four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.

Clinical practices and outcomes in elderly hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND AND OBJECTIVES

Demand for hemodialysis among elderly patients is increasing worldwide. Although clinical care of this high-risk group is complex and challenging, no guidelines exist to inform hemodialysis practices. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to assess dialysis practices and associated outcomes among elderly versus younger patients on chronic in-center hemodialysis in 12 countries.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Clinical characteristics, dialysis practices, and outcomes of elderly versus younger patients were compared among participants in four DOPPS regions in 2005 through 2007.

RESULTS

Although participant mean age increased over time in all DOPPS countries, the percentage of elderly varied widely. Overall, comorbidities and malnutrition were more common in the elderly. Fistulae were used less frequently among elderly versus younger patients in Europe and North America but not in Australia, New Zealand, and Japan. No difference in treatment time was observed between elderly and younger patients after normalizing for body weight. In all regions, ultrafiltration rates were lower among elderly patients. Elderly patients reported poorer quality of life with respect to the physical but not mental component scores. Mortality risk was three- to sixfold higher in the elderly group, whereas causes of death overall were similar for elderly and younger patients.

CONCLUSIONS

Elderly patients represent a different proportion of DOPPS participants across countries, possibly reflecting differences in policies and clinical practices. In general, hemodialysis practices in the elderly reflected each region's clinical patterns, with some variation by age group depending upon the practice.

Characteristics of elderly patients with diabetes and end-stage renal disease

Because of a combination of demographic and social factors, such as the aging of the population in general, increased incidence of diabetes, and more liberal criteria for renal replacement therapy initiation, the proportion of the end-stage renal disease (ESRD) patients with diabetes who are considered elderly is currently the fastest growing segment of incident ESRD population. Despite the fast growth of this group, it is poorly characterized in current literature. In this review, we attempt to summarize the data available to date regarding demographic composition, outcomes, choice of renal replacement therapy, and other management issues including renal transplantation. There is significant evidence that the elderly diabetic patients might differ from the general dialysis population regarding renal replacement modality, vascular access for dialysis, and that guidelines addressing chronic kidney disease (CKD) issues such as nutrition and blood pressure may need modification in this ESRD subgroup. At the same time, other areas such as anemia and bone mineral metabolism have not been adequately studied. Lastly, despite lower rates of kidney transplantation in this population, it confers significant survival advantages, similar to that seen in younger populations. As the fastest growing group in the incident ESRD population, these patients have issues related to clinical management, which represent very important areas for future research.

O idoso em diálise

Em decorrência, principalmente, do envelhecimento populacional e mudanças no perfil epidemiológico, tem-se observado um crescente aumento do número de idosos em terapia renal substitutiva. O presente relato aponta e descreve os principais aspectos e as características do idoso em diálise; e destaca como imprescindível o atendimento em saúde, incluindo o cuidado de enfermagem, direcionado e especializado, diante das especificidades e necessidades desta parcela de pacientes nos centros de diálise.

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.

The enigma of hypertensive ESRD: observations on incidence and trends in 18 European, Canadian, and Asian-Pacific populations, 1998 to 2002

BACKGROUND

Despite improved treatment of hypertension and decreasing rates of stroke and coronary heart disease, the reported incidence of hypertensive end-stage renal disease (ESRD) increased during the 1990s. However, bias, particularly from variations in acceptance into ESRD treatment (ascertainment) and diagnosis (classification), has been a major source of error when comparing ESRD incidences or estimating trends.

METHODS

Age-standardized rates were calculated in persons aged 30 to 44, 45 to 64, and 65 to 74 years for 15 countries or regions (separately for the Europid and non-Europid populations of Canada, Australia, and New Zealand), and temporal trends were estimated by means of Poisson regression. For 10 countries or regions, population-based estimates of mean systolic blood pressures and prevalences of hypertension were extracted from published sources.

RESULTS

Hypertensive ESRD, comprising ESRD attributed to essential hypertension or renal artery occlusion, was least common in Finland, non-Aboriginal Australians, and non-Polynesian New Zealanders; intermediate in most European and Canadian populations; and most common in Aboriginal Australians and New Zealand Maori and Pacific Island people. Rates correlated with the incidence of all other nondiabetic ESRD, but not with diabetic ESRD or community rates of hypertension. Between 1998 and 2002, hypertensive ESRD did not increase in Northwestern Europe or non-Aboriginal Canadians, although it did so in Australia.

CONCLUSION

Despite the likelihood of classification bias, the probability remains of significant variation in incidence of hypertensive ESRD within the group of Europid populations. These between-population differences are not explained by community rates of hypertension or ascertainment bias.

Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes

The fate of octogenarians reaching end-stage renal disease (ESRD) is poorly defined, and implicit dialysis rationing may be practiced in this age group. The main objectives of this study were to analyze the characteristics of pre-ESRD octogenarians offered dialysis or not and to identify factors influencing mortality while on dialysis, to improve prognosis assessment and decision-making. In this single-center cohort, 146 consecutive pre-ESRD octogenarians were referred to a nephrology unit over a 12-yr period (1989 to 2000). Main outcome measures were baseline characteristics of patients offered dialysis and conservative therapy and overall and 1-yr survival according to effective treatment. A therapeutic decision was made for 144 patients. Octogenarians who were not proposed dialysis (n = 37) differed from those who were proposed dialysis (n = 107) mainly in terms of social isolation (43.3% versus 14.7%; P = 0.03), late nephrologic referral (51.4% versus 28.9%; P = 0.01), Karnofsky score (55 +/- 18 versus 63 +/- 20; P = 0.03), and diabetic status (22.2% versus 6.5%, P = 0.008). Six patients refused the dialysis proposal. During the 12-yr observation period, 99 patients died (68.7%). Median survival was 28.9 mo (95% CI, 24 to 38) in patients undergoing dialysis, compared with 8.9 mo (95% CI, 4 to 10) in patients treated conservatively (P < 0.0001). In multivariable piecewise Cox analysis, independent predictors of death within 1 yr on dialysis were poor nutritional status, late referral, and functional dependence. Included in a survivor function, these covariates predict groups with low and high 1-yr mortality risk. Beyond 1 yr on dialysis, the only independent predictor of death was the presence of peripheral vascular disease. It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians. Although most patients on dialysis experienced a substantial prolongation of life, identification of mortality predictors in this age group should improve the process of decision-making regarding the expected benefit of renal replacement therapy.