Ajay K. Singh, MBBS, FRCP, MBA
Brigham and Women’s Hospital
Harvard Medical School
In a previous editorial, I made the case for the federal government funding a Dialysis Moonshot initiative, set up similarly to the Obama administration’s Cancer Moonshot that was spearheaded by Vice President Joe Biden.
In occasional articles, I intend to cover areas of dialysis care where research is very limited and the impact of research on patient lives could be substantial. One specific area that could be funded is research examining the benefit of initiating dialysis versus maximal conservative therapy in the very elderly (defined as age ≥75 years). Outcomes could include health-related quality of life (QoL) and mortality.
The number of dialysis patients older than 75 is growing rapidly. However, outcomes among these patients are very poor. USRDS data from 2018 report that among those 75 years and older, expected remaining lifetime in years is 3.3 for men and 3.6 years for women on dialysis, compared with 7.6 and 8.3 years for men and women in the general population, respectively1. Indeed, life span on dialysis steeply declines for both men and women after the age of 60, and mortality is nearly doubles for those >75 years of age (195 and 188 vs 364 and 339 deaths per 1000 patient years for men and women, <75 vs >75 years, respectively).1
Berger and Hedayati, in a paper in a 2012 CJASN2, discuss the challenges with renal replacement in the elderly. Factors that influence higher mortality include increased frailty, falls, and functional/cognitive impairment. Jennifer S. Scherer and Markus Bitzer writing in Kidney News Online3 discuss the limitations of current guidelines with respect to dialysis care among the elderly: They are “disease oriented and with a one-size-fits-all approach that pays little attention to QoL.” The authors state that there is no right answer for an elderly patient: “A time-limited trial begins with the identification of patient-specific goals, often relevant to QoL and geriatric syndromes, with planned re-evaluations to assess the patient’s perceptions of the benefits and burdens of dialysis. This continuous dialogue also allows for a fluid transition into advance care planning. Advance care planning with dialysis patients can promote the use of hospice, a benefit often underused in this population. In the general population advance care planning is associated with fewer intensive procedures at the end of life, death at the location of choice, increased patient satisfaction, and increased use of hospice.”
In a recent longitudinal comparison of older patients beginning dialysis versus enrolling in maximum conservative therapy, the GOLD (Older Patients Starting Dialysis) study, van Loon and colleagues4 reported four key findings: (1) Patients starting dialysis compared with patients choosing conservative care had similar overall QoL; (2) over time, QoL in the dialysis group remained stable versus a small decline of QoL observed in the conservative group; (3) hospitalization was significantly higher among dialysis patients compared with conservative patients, despite conservative patients being older; and (4) survival at 12-months in patients over 80 years old was not significantly longer in patients initiating dialysis compared with maximum conservative care patients.
There are currently major gaps in understanding what should be the optimal care of elderly patients with kidney failure. Data suggest that lifespan is limited regardless of whether these patients are treated with dialysis or maximal conservative therapy. A sensible approach might be to focus on quality of life. Figuring this out could be a goal of a Dialysis Moonshot!
1. U.S. Renal Data System: USRDS 2018, Mortality Chapter: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States, Bethesda, MD, National Institute of Health, National Institute of Diabetes and Digestive and Kidney Disease P 398 https://www.usrds.org/2018/view/v2_05.aspx
2. Berger JR, Hedayati SS. Renal replacement therapy in the elderly population. Clin J Am Soc Nephrol. 2012;7(6):1039–1046. doi:10.2215/CJN.10411011
3. Scherer JS, Bitzer M. Geriatric Issues in the Elderly Dialysis Population. https://www.kidneynews.org/kidney-news/special-sections/geriatric-nephrology/geriatric-issues-in-the-elderly-dialysis-population
4. van Loon IN, Goto NA, Bots ML, et al. Quality of life after the initiation of dialysis or maximal conservative management in elderly patients: a longitudinal analysis of the Geriatric assessment in Older patients starting Dialysis (GOLD) study age groups. BMC Nephrol. Volume 20, Article number: 108 (2019)