A recent US study has found that over three years, older patients with kidney failure who started dialysis immediately survived for only a short while longer than those who never started the treatment.
The researchers, who had analysed data from a simulated trial involving records from more than 20 000 older patients (average age: about 78), found that their survival gains were only “modest”, reports The New York Times.
How modest? Over three years, older patients with kidney failure who started dialysis right away lived for an average of 770 days – just 77 days longer than those who never started it.
“I think people would find that surprising,” said Dr Manjula Tamura, a nephrologist and researcher at Stanford and a senior author of the study, which was published in the journal Annals of Internal Medicine. “They would have expected a greater difference.”
‘Trade-off’ in prolonging life
Even before New York’s Georgia Outlaw met her new nephrologist, she had made her decision: although her kidneys were failing, she didn’t want to begin dialysis.
Outlaw (77), a retired social worker, knew many relatives and friends with advanced kidney disease. She watched them travel to dialysis centres three times a week, month after month, to spend hours having waste and excess fluids flushed from their blood.
“They’d come home weak and tired and go to bed,” she said. “It’s a day until they feel back to normal, and then it’s time to go back to dialysis again. I didn’t want that regimen.”
She told her doctors: “I’m not going to spend my days bound to some procedure that’s not going to extend my life or help me in any way.”
She was mistaken on one point – dialysis can prolong the lives of patients with kidney failure, but modestly, according to the study’s findings.
Moreover, the team found patients also spent less time at home; they were in a hospital, a nursing home or a rehab centre for about 15 more days than those who never started dialysis.
Another group didn’t begin dialysis early but continued with “medical management” (which could help alleviate symptoms if needed), though half of them started dialysis at some later point. They lived for about the same amount of time as those who started dialysis right away.
“Our field has really been debating about the role of dialysis in patients who develop kidney disease in old age,” Tamura said. “It’s lifelong therapy and a major change to your lifestyle. It can lengthen life, but there are trade-offs.”
About a third of the population over 65 has chronic kidney disease, according to the US Renal Data System. The pluses and minuses of treatment add up differently for them than for younger patients.
Among older adults who progress to kidney failure, most also have diabetes and many have heart failure, pulmonary disease or other serious chronic illnesses. They may not be candidates for transplants, the only cure for kidney failure, either because they’re too ill or frail for surgery, or because the wait for donated kidneys can be years-long.
About 13% of the patients with kidney failure who register with the Renal Data System begin peritoneal dialysis at home – a more common treatment in other countries but one that, with Medicare incentives to providers, is gaining ground in the United States, too. It involves filtering blood through the abdominal lining.
But a great majority, almost 84% in 2021, still turn to dialysis centres, despite the challenges of transportation and the significant time commitment.
Haemodialysis, the treatment offered in centres, requires a catheter, graft or fistula to allow access to a patient’s blood vessels, and it can cause side effects like infections, fatigue and itching. And, as this latest study indicates, dialysis often means more time spent in health care centre, where most older adults don’t want to be.
The alternative to dialysis goes by various names – medical management, conservative kidney management, supportive kidney care. In this scenario, nephrologists monitor their patients’ health, educating them about behavioural approaches, prescribing anti-nausea drugs like Zofran and diuretics like Lasix to reduce fluid retention, and adjusting their doses as needed.
Outlaw, for example, takes a diuretic, two blood pressure drugs and a phosphate binder, along with iron and calcium. Five years after her kidney failure diagnosis, she’s feeling fine, though sometimes a little weak or tired, she said.
Not everyone in conservative management is terribly active. “Some of my other patients are in wheelchairs,” said Dr Rasheeda Hall, a geriatric nephrologist who provides conservative care for Outlaw and others at the Durham VA Health Care System.
“They’re more complicated – we have to pay a lot more attention. But they sleep in their own beds. They’re not in the hospital often. They have a better quality of life.”
Some older kidney patients find that strategy preferable, even if death should come a couple of months earlier.
Dialysis “is definitely still the default,” Hall added.
Options
Researchers at the University of Washington have developed a “decision aid” – a booklet explaining conservative kidney management and its pros and cons – and tried it out on patients 75 and older with advanced kidney disease and their families. The goal: to prompt discussion of conservative management with a healthcare provider.
In the groups that received the booklet, about a quarter of patients and their relatives had such conversations. But among those who didn’t get the booklet, only 3% of patients discussed conservative management with a provider, and none of their family members did.
“I was quite pleased with the results,” said Dr Susan Wong, a nephrologist and lead author of the study. “It can be intimidating for patients to bring up alternatives when a provider is pushing or recommending or positioning dialysis as the only right thing to do.”
In her clinic, she said, about a third of patients go to dialysis centres, a third begin dialysis at home and a third opt for conservative management without dialysis.
Practices are shifting somewhat among kidney patients and their doctors. The most recent statistics from the Renal Data System, for instance, show that the use of peritoneal dialysis at home more than doubled from 2008 to 2021; the proportion of patients traveling to dialysis centres declined.
“Several things in the kidney world appear to be getting better,” said Dr Kevin Abbott, programme director in the division of kidney, urologic and haematologic diseases at the National Institute of Diabetes and Digestive and Kidney Diseases.
The proportion of older Americans with kidney disease has fallen, in part reflecting the wider use of more effective blood pressure drugs in recent decades, he said. The new diabetes drugs that help reduce weight and blood sugar also show promise for treating kidney disease.
But it still often falls to patients themselves and their families to question whether they want to start dialysis, to ask about other options like conservative kidney management, and to weigh their choices.
If they’re waiting for healthcare professionals to alert them to the alternatives, they may have to wait quite a while.
Study details
Effect of starting dialysis versus continuing medical management on survival and home time in older adults with kidney failure: a target trial emulation study
Maria E. Montez-Rath, I-Chun Thomas, Suan Wong et al.
Published in Annals of Internal Medicine on 20 August 2024
Abstract
Background
For older adults with kidney failure who are not referred for transplant, medical management is an alternative to dialysis.
Objective
To compare survival and home time between older adults who started dialysis at an estimated glomerular filtration rate (eGFR) less than 12 mL/min/1.73 m2 and those who continued medical management.
Design
Observational cohort study using target trial emulation.
Setting
US Department of Veterans Affairs, 2010 to 2018.
Participants
Adults 65 or older with chronic kidney failure and eGFR below 12 mL/min/1.73 m2 who were not referred for transplant.
Intervention
Starting dialysis within 30 days versus continuing medical management.
Measurements
Mean survival and number of days at home.
Results
Among 20 440 adults (mean age, 77.9 years [SD, 8.8]), the median time to dialysis start was 8.0 days in the group starting dialysis and 3.0 years in the group continuing medical management. Over a 3-year horizon, the group starting dialysis survived 770 days and the group continuing medical management survived 761 days (difference, 9.3 days [95% CI, −17.4 to 30.1 days]). Compared with the group continuing medical management, the group starting dialysis had 13.6 fewer days at home (CI, 7.7 to 20.5 fewer days at home). Compared with the group continuing medical management and forgoing dialysis completely, the group starting dialysis had longer survival by 77.6 days (CI, 62.8 to 91.1 days) and 14.7 fewer days at home (CI, 11.2 to 16.5 fewer days at home).
Limitation
Potential for unmeasured confounding due to lack of symptom assessments at eligibility; limited generalisability to women and nonveterans.
Conclusion
Older adults starting dialysis when their eGFR fell below 12 mL/min/1.73 m2 who were not referred for transplant had modest gains in life expectancy and less time at home.
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