Nondialytic Therapy May Benefit Selected Elderly ESRD Patients
SEATTLE—Nondialytic therapy (NDT) for selected elderly patients with end-stage renal disease (ESRD) is growing in popularity in the United Kingdom and Europe, but it is rarely used in the U.S., according to a study at the 33rd Annual Dialysis Conference. Investigators believe the use of NDT for elderly ESRD patients in the U.S. should be reappraised.
“This study was carried out because all around the world, particularly in Europe and the United Kingdom, there has been this movement to assess patient outcomes with dialytic therapy compared to NDT for older patients approaching ESRD, and at least some data suggest that patient outcomes with respect to quality of life was better with NDT, even though older patients on dialysis may live longer,” said study investigator Macaulay Onuigbo MD, MBA, FASN, Associate Professor of Medicine at the Mayo Clinic in Rochester, Minn., and Attending Nephrologist/Hypertension Specialist/Transplant Nephrologist, Mayo Health Clinic System, Eau Claire, Wis.
Dr. Onuigbo and his colleagues analyzed a Northwestern Wisconsin Mayo Clinic dialysis population for recent NDT activity. The analysis focused on 166 ESRD patients, of whom 82 (49%) were age 70 or older. A total 46 patients were aged 70-79 years and 36 were aged 80-89. The vast majority of these patients had extensive and significant multiple comorbidities, but NDT use was virtually nonexistent.
“From anecdotal experience and evidence, we were not surprised at all by our finding of almost absence of the practice of NDT,” Dr. Onuigbo told Renal & Urology News. “The older patients tended to have a poorer quality of life with multiple procedures and multiple hospital admissions. The older patient who approaches ESRD gradually and with a significant load of medical comorbidities could indeed be very actively managed in a multidisciplinary team to take care of symptoms, anemia, volume control, hyperphosphatemia and hyperparathyroidism, hypertension, etc., adequately without the need for dialytic therapy.”
Elderly patients managed with NDT have outcomes and overall survival similar to their counterparts treated with dialysis, but with a better quality of life that includes fewer hospitalizations, Dr. Onuigbo said.
“Nephrology fellowship curricula have yet to address this important issue,” he said. “As a result, most nephrologists, as with most other physician groups in the U.S., have struggled with end-of-life care decisions and as a result physician counseling of patients and families on medical decision making often leaves a lot to desire.”
Additionally, practices may be financially motivated to steer patients to dialysis and patients and families may have exaggerated expectations as to what dialysis can achieve for elderly ESRD patients with multiple comorbidities, Dr. Onuigbo said.
He noted that the phenomenon of “technological imperative” tends to drive medicine much more in the U.S. than anywhere else in the world.
NDT should be seen as another active management paradigm and an alternative to dialytic therapy in a specific group of older ESRD patients, he said. This form of conservative management should not be seen as “no dialysis” alone, but as an active medical management without dialysis. Clinicians should take into account morbidity scores, anticipated life expectancy, and functional capacity of the patient, he said. Chronological age should not be the only factor considered. “The use of therapies in a rational and appropriate fashion must be distinguished from rationing,” Dr. Onuigbo said.