In the News: Nephrologist Calls for ‘Age-Attuned Approach’ to Chronic Kidney Disease

We are grateful to Caring for Ages allowing us to reprint this article on CKD.  This is a balanced article that informs us on the need to help our patients make informed decisions about starting and continuing dialysis, as well as address common causes of distress appropriately.

Shared with permission from AMDA/Elsevier/Caring for the Ages

Nephrologist Calls for ‘Age-Attuned Approach’ to Chronic Kidney Disease

Christine Kilgore
PHOENIX — Conservative management and supportive care may offer elderly patients with end-stage renal disease (ESRD) the same survival as dialysis, as well as less functional decline, fewer hospitalizations, and better satisfaction with life, said Fahad Saeed, MD, at AMDA – the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference.

With the increasing prevalence of end-stage renal disease in older and medically complex patients, “we need to take an age-attuned approach to discussions,” he said. This means being prepared to present estimates of prognosis with and without dialysis and to thoroughly discuss conservative management when contemplating dialysis, said Dr. Saeed, assistant professor of medicine in the divisions of nephrology and palliative care at the University of Rochester Medical Center (URMC).
Whether or not dialysis prolongs survival in the elderly is “an area most physicians struggle with,” he told attendees at the Saturday morning breakfast session. At least several studies have found little or no survival benefit with dialysis compared with conservative management in older patients, and the literature signals that any survival advantage with dialysis is significantly reduced — if not lost — with the presence of multiple comorbid conditions, especially with ischemic heart disease (Nephron Clin Pract 2003;95:c40–6; Palliat Med2013;27:829–39; Nephrol Dial Transplant 2007;22:1955–62).
In the largest retrospective study to date of elderly patients with stage 5 chronic kidney disease, investigators in the United Kingdom studied 844 patients who were treated with either dialysis (82%) or conservative management (18%). The patients had been counseled for either dialysis or a conservative approach based on their comorbidity burden, but they made the final decision themselves.
The median survival was higher in the dialysis patients (67 vs. 21 months) overall, but in patients who were both older than 75 and had high comorbidity, the difference was statistically insignificant (25.9 vs. 20.4 months), the researchers found (Nephrol Dial Transplant 2011;26:1608–1614).
“In patients with a low comorbidity burden, dialysis outperformed conservative management, but in patients with a severe comorbidity burden, this survival advantage was lost,” said Dr. Saeed, who leads the geriatric chronic kidney disease (CKD) clinic at URMC.
In addition to a high comorbidity burden, predictors of poor prognosis with dialysis include impaired functional status and frailty, as well as malnutrition as indicated by serum albumin of less than 2 g/dL. For help with prognosis, one may use the French Rein Registry score system (described in Nephrol Dial Transplant2009;24:1553–1561) or the Charleston Comorbidity Index, Dr. Saeed advised.
A discussion of likely functional decline after dialysis in elderly patients is also important to the decision-making process, he said. In “a study that we all need to be familiar with,” investigators identified all 3,702 nursing home residents in the United States who were starting dialysis during a period of approximately 2 years and for whom at least one measure of functional status was available before the initiation of treatment.
Three months after dialysis initiation, functional status was maintained in only 39% of these nursing home residents. By 12 months, 58% of the patients had died, and predialysis function was maintained in only 13% (N Engl J Med 2009;361:1539–1547).
Research has also shown that the rates of hospitalization in elderly dialysis patients are double the rates seen in elderly patients receiving supportive care. And although there are fewer data on quality of life, research has demonstrated that life satisfaction scores decrease significantly after dialysis initiation but remain stable in conservative management.
The caregivers of elderly dialysis patients, moreover, experience a significant burden. On average they spend 56 to 70 hours a week on care, research has shown, and “all of their quality of life components are affected,” Dr. Saeed said.
“Most patients have similar wishes,” he noted. “They want adequate symptom control and management. They want to avoid inappropriate prolongation of dying, and they don’t want to burden their families. They want a sense of control, and they want to strengthen their relationships with their loved ones.”
An Australian study of 151 adults with stages 3–5 CKD looked at how treatment characteristics influenced patients’ preferences for dialysis compared with conservative care. The main finding — that patients were willing to forego 7 months of life expectancy to reduce the number of required visits to the hospital and 15 months of life expectancy to increase their ability to travel — was “very interesting,” Dr. Saeed said.
Advance directives or designated heath care agents are essential for older ESRD patients, whose annual mortality rate of about 24% (according to the U.S. Renal Data System) is higher than that of most cancer patients. Compared with Medicare beneficiaries who have cancer, older ESRD patients also spend twice as many days in the hospital during the last month of life and are three times more likely to undergo an invasive procedure such as intubation or cardiopulmonary resuscitation (CPR).
Patients with chronic renal failure have particularly poor outcomes after CPR. Yet in an ongoing study led by Dr. Saeed, 55% of those who completed advance directives were full code, and only 9% had a do-not-resuscitate (DNR) status. The study highlights additional deficiencies: fewer than half (44%) of the patients had end-of-life discussions with their family members/friends, and only 9% had the opportunity to discuss advance care planning with their doctors.
“We, the medical community, clearly need to do a better job,” Dr. Saeed said. Advance care planning should be initiated early in the continuum of CKD, he said.
Christine Kilgore is a freelance writer in Falls Church, VA.


Editor’s Note

Any patient with significant functional morbidity or high chronic illness burden (i.e., nursing home dwellers) should have a mandatory palliative care consultation before starting dialysis. With all due respect to our nephrologist colleagues, it’s my experience that they do not provide enough information on non-dialysis management for our patients and their families to make an informed decision. In fact, some dialysis centers have policies that essentially will not accept patients who have a DNR. This article references study findings that in this population, dialysis doesn’t significantly extend prognosis — along with the observation of virtually everyone that dialysis is a huge burden—which makes it much more reasonable as an option for patients who want to feel that they are not “giving up” or making a decision that will clearly shorten their life. Sometimes patients just want permission to say no to life-altering interventions like dialysis, which they may not receive from their nephrologists, and we can help with that. Words are important, and for frail dialysis patients, they are really in the dying process as far as nearing death temporally, with or without dialysis — so using that language about prolonging the dying process as opposed to prolonging life sometimes resonates with patients when a realistic discussion is undertaken. The pearls as far as symptom management are also very useful, and hospice or palliative care services can help in cases where primary management seems to be failing.

—Karl Steinberg, MD, CMD, HMDC


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Shared with permission from AMDA/Elsevier/Caring for the Ages