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Octogenarians and Nonagenarians Starting Dialysis in the United States

Manjula Kurella, MD, MPH; Kenneth E. Covinsky, MD, MPH; Alan J. Collins, MD; and Glenn M. Chertow, MD, MPH
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From the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, San Francisco, California, and the United States Renal Data System, Minneapolis, Minnesota.


Disclaimer: The data reported here have been supplied by the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the U.S. government.

Grant Support: Dr. Kurella was supported in part by the American Society of Nephrology–Association of Subspecialty Professors Junior Development award in Geriatric Nephrology, funded through Atlantic Philanthropies, the American Society of Nephrology, and the John A. Hartford Foundation. Dr. Chertow was supported in part by NIH and NIDDK (RO1 DK58411) and NIH and NIDDK (RO1 DK01005).

Potential Financial Conflicts of Interest: Grants received: G.M. Chertow (National Institutes of Health); Grants pending: G.M. Chertow (National Institutes of Health). Dr. Collins is the president of the National Kidney Foundation.

Requests for Single Reprints: Manjula Kurella, MD, MPH, Division of Nephrology, University of California San Francisco, UCSF Laurel Heights Suite 430, 3333 California Street; e-mail, manjula.kurella@ucsf.edu.

Current Author Addresses: Drs. Kurella and Chertow: Division of Nephrology, University of California, San Francisco, UCSF Laurel Heights Suite 430, 3333 California Street, San Francisco, CA 94118-1211.

Dr. Covinsky: Division of Geriatrics, University of California, San Francisco, San Francisco Veterans Affairs Medical Center, VAMC 181G, San Francisco, CA 94143.

Dr. Collins: United States Renal Data System, 914 South 8th Street, Suite D-206, Minneapolis, MN 55404.

Author Contributions: Conception and design: M. Kurella, G.M. Chertow.

Analysis and interpretation of the data: M. Kurella, K.E. Covinsky, G.M. Chertow.

Drafting of the article: M. Kurella, G.M. Chertow.

Critical revision of the article for important intellectual content: M. Kurella, K.E. Covinsky, A.J. Collins, G.M. Chertow.

Final approval of the article: M. Kurella, K.E. Covinsky, A.J. Collins, G.M. Chertow.

Statistical expertise: M. Kurella, G.M. Chertow.

Obtaining of funding: M. Kurella.


Ann Intern Med. 2007;146(3):177-183. doi:10.7326/0003-4819-146-3-200702060-00006
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In this population-based study of patients with incident ESRD, we identified many important trends among the very elderly. Dialysis initiation among octogenarians and nonagenarians increased dramatically from 1996 to 2003, translating to a near doubling of the number of patients with incident ESRD who are older than 80 years of age. We observed this increase in dialysis initiation across most demographic subgroups, and it was approximately similar among men and women and among white and black patients. Survival after dialysis initiation was often poor among octogenarians and nonagenarians and was substantially lower than that of the age-matched population, as only 54% of the cohort was alive at 1 year. In addition to age, clinical characteristics, including nonambulatory status and the number of comorbid conditions, were associated with very high mortality rates after dialysis initiation.

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Figure 1.
Incidence of dialysis initiation from 1996 to 2003 by year and age group (per 100 000 persons in U.S. population), adjusted for sex and race.
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Figure 2.
Survival of octogenarians and nonagenarians at dialysis initiation by age group (top), ambulatory status (middle), and number of comorbid conditions (bottom).

In the bottom panel, comorbid conditions include albumin concentration <35 g/L, anemia, underweight, congestive heart failure, diabetes, ischemic heart disease, chronic obstructive pulmonary disease, cancer, cerebrovascular disease, and peripheral vascular disease.

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Octogenarians, Nonagenarians and Even Centenarians Starting Dialysis: Survival or Withdrawal?
Posted on February 24, 2007
T. S. Dharmarajan
Our Lady of Mercy Medical Center ( New York Medical College)
Conflict of Interest: None Declared
Octogenarians, Nonagenarians and Even Centenarians Starting Dialysis: Survival or Withdrawal? To the Editor: The observational study involving octogenarians and nonagenarians initiating dialysis published in the Annals was most educational (1). We add our experience with two centenarians initiating dialysis in the Bronx, but differing in outcomes. The first was a wheelchair bound diabetic female, initiated on dialysis in Oct 2002 through a permanent catheter, at age 100 years, 10 months. On dialysis, she substantially improved her function, activities of living and quality of life, and cooperated with dialysis for 2.5 years until her demise at 103 (2). The second was a 102 year old nursing home female with Chronic Kidney Disease (CKD) who decompensated from pneumonia. She underwent a time-limited trial of dialysis (January 2007); after 2 weeks on treatment, she was withdrawn from dialysis as she tolerated treatments poorly, with no improvement in quality of life. The cases differ in outcomes, demonstrating survival in one and withdrawal from dialysis in another, indicating need for judgment in initiating dialysis in the old. In particular, dementia predicts mortality (3); age over 85 years and nonambulatory status predict poor survival (1); age affects vascular suitability for access (4). However our wheelchair bound diabetic centenarian did well for 30 months (2), suggesting that all elderly are not alike. Age alone is a basis to deny dialysis to geriatric patients in some countries. Finally withdrawal from dialysis is common in the old (5) and a common cause of death in the elderly on dialysis; age > 65, whites, females, diabetes and nursing home residents (as with our second case) are associations (5). Inevitable trends indicate octogenarians to centenarians requiring dialysis. Table 1 presents some considerations when initiating dialysis, including choices of long term or time-limited dialysis, with the option for withdrawal from treatments; but best of all would be attempts to tackle the culprit, i.e. slow progression of CKD!

Table. Initiating dialysis in the old: some considerations

Assess comorbidity, especially cognition
Timely involvement of a nephrologist
Serum creatinine unreliable in the elderly; calculate GFR
Address geriatric problems
Plan timely creation of vascular access
Access choice: graft, catheter or arterio-venous fistula
Goals: improve function, quality of life, rather than longevity
Is it long term or time-limited trial of dialysis?
Is withdrawal from dialysis an option?
Advance Directives in place?
References:

1. Kurella M, Covinsky KE, Collins AJ et al. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007; 146:177-83.

2. Dharmarajan TS, Kaul N, Russell RO. Dialysis in the old: A centenarian nursing home resident with ESRD. J Am Med Dir Assoc. 2004; 5: 186-91

3. Rakowski DA, Caillard S, Agodoa LY et al. Dementia as a predictor of mortality in dialysis patients. Clin J Am Soc Nephrol. 2006; 1: 1000-5

4. Dharmarajan TS. Use of the radial artery for hemodialysis access: Does age affect artery flow and utility? Arch Surgery. 2004; 139: 1025

5. Cohen LM, Germain MJ, Poppel DM. Practical considerations in dialysis withdrawal. To have that option is a blessing. JAMA. 2003; 289: 2113-19

Conflict of Interest:

None declared

Is dialysis the best choice for octogenarians and nonagenarians?
Posted on March 26, 2007
michael j germain
baystate medical center
Conflict of Interest: None Declared

Kurella et al (1) address a critical issue confronting our health care system: an expanding and very elderly population with chronic kidney disease (CKD) and the need to understand more fully the role of dialysis for this sector of the CKD population. The data they present is compelling; 10-15 months after starting dialysis, half of the patients over 80 years old are dead. Median survival for a 90 year old starting dialysis is around 8 months, compared to 57 months for 90"“94 year olds in the general population. This evidence that they present is crucial for informing health care policy, clinical practice, and future prospective research.

They do not, however, discuss the consequences of not starting dialysis in this very elderly population. Recent studies (2,3) have raised questions about the survival advantage provided by dialysis, especially for the very elderly. Smith et al (2) identified a group of patients recommended by their renal team for "conservative" (non-dialytic) management, and demonstrated little difference in survival between those who (despite advice) opted for dialysis, and those who accepted conservative management. Murtagh et al identified little difference in survival in elderly patients with higher levels of co-morbidity, especially when this co-morbidity included ischemic heart disease (3), although the small numbers and retrospective design imposed some limitations on their study.

Prospective research, with larger numbers, is urgently needed to inform the nephrology community and their increasingly elderly patients as what they can expect if they choose dialysis as against "conservative" management. In the UK, conservative management is becoming more widely discussed and offered by renal units (4), and the increasing availability and involvement of hospice/palliative care should help facilitate our patients to die well. We need more evidence to help us advise our patients and to enable a better informed choice around dialysis, and we need urgently to answer the question: "Do our patients suffer more with dialysis (in particular considering access surgery, hospitalizations, and dialysis-related morbidity), with little gain in survival"!?

References:

(1) Kurellla M, Covinsky K£E, Collins AJ and Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007;146: 177-183

(2) Smith C, Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clinical Practice 2003; 95(2):c40-c46.

(3) Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease Stage 5. Nephrology Dialysis Transplantation, 2007 (in press).

(4) Gunda S, Smith S, Thomas M. National Survey of Palliative Care in End-Stage Renal Disease in the United Kingdom. Nephrology Dialysis Transplantation 2004;20:392-5.

Conflict of Interest:

None declared

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