Dialysis in the Elderly

The rate of patients >75 years of age initiating dialysis has grown substantially in the U.S. over the past two decades.  This has to do with several factors, including improvements in medical technology enabling people to live long enough to develop advanced CKD, but also an increasing expectation for aggressive medical care late in life.    In the U.S., the fact that the Social Security Act in 1972 pays for dialysis in all individuals also plays a role in this statistic.  The "Precious Bodily Fluids" blog recently posted an extensive review of the subject in power point presentation form.  

But how do elderly patients do once they have started dialysis?  The answer is complex--and not surprisingly it depends on the patient.  According to several studies, age itself is not a preclusion for starting dialysis--some patients > 90 years old can even do well provided their functional status is reasonable going in.  It turns out that the degree of comorbidity a patient has is a much better predictor of how they will do on dialysis than age alone.  

As an example, in this 2007 NDT study by Murtagh et al, the investigators performed a retrospective analysis of 129 patients > 75 years of age who were referred to a multi-disciplinary pre-dialysis care clinic.  They compared patients who chose dialysis with those who chose "conservative care"--which involved the decision to NOT begin dialysis but rather attempting to control their symptoms with blood pressure control, diet, etc.  The primary outcome measured was survival after reaching a GFR of <>

The top graph (A) shows the Kaplan-Meier curve describing patients WITH ISCHEMIC HEART DISEASE as a comorbidity.  You can see that the survival advantage in the dialysis group compared to the conservative care group virtually disappears.  In the bottom graph (B) is charted patients WITHOUT ischemic heart disease--and shows a robust and obvious survival advantage in the dialysis group.

These factors should ideally be discussed in educating elderly patients about the advantages and disadvantages of starting dialysis.  Patients >75 years of age with Stage V CKD and underlying ischemic heart disease should know that their likelihood of dying with or without dialysis is virtually the same.  Obviously, every patient is different and deserves to make their own decisions about end-of-life care.  But perhaps we should be adopting an evidence-based model similar to what some (not all) oncologists use--in which patients who do not meet a certain performance status are often not even deemed suitable to receive aggressive chemotherapy, with the knowledge that it has the potential to do more harm than good.