Placing Very Elderly Patients on RRT
Jody A. Charnow, Editor
As a venue for presenting important research on kidney disease to the world, Kidney Week never disappoints.
In addition to the usual plethora of new studies of promising investigational therapeutics and new approaches to the care of patients with chronic kidney disease and end-stage renal disease, the conference had a number of intriguing new epidemiologic studies.
One of the more eye-opening ones was a retrospective investigation that characterized what happens to the very elderly after they start renal replacement therapy (RRT) in the hospital. The statistics that emerged raise questions about the wisdom of placing these old patients on RRT.
The study, led by Bjoerg Thorsteinsdottir, MD, of Mayo Clinic, Rochester, Minn., found extremely high rates of early and overall mortality.
The researchers reviewed the medical records of 379 patients aged 75 years and older starting any form of RRT at the Mayo Clinic Rochester Midwest dialysis network. Of the 379 patients, 286 (76%) were started on RRT in the hospital after an acute illness or surgery. A total of 173 (60%) of those began with continuous RRT in the intensive care unit (ICU). Of 254 hospital-initiated patients admitted from independent living, only 95 (37%) were discharged home.
One hundred and four patients (27%) died in less than 30 days and 140 (36%) died in less than 90 days. The six- and 12-month survival rates were 60% and 49%, respectively. Among the patients who started RRT in the hospital, 110 (43%) died during the index hospitalization.
According to Dr. Thorsteinsdottir, patients frequently had no idea that their kidneys had failed and they would need dialysis.
In addition, many elderly patients and their families expressed regret about having started RRT. Many elderly people have strong feelings about not wanting to be dependent on others and not being able to maintain their independence, she observed. Based on the new study, she said, clinicians can inform patients that if they are sick enough to be in the ICU and needing RRT, they are unlikely to make it back home and very likely to die in the short term.
Physicians and other medical professionals rightfully see it as their professional and ethical obligation to prolong life by any reasonable means possible. The sobering findings of Dr. Thorsteinsdottir's study should remind clinicians that patients—especially very old patients—may not want life prolonged if the quality of that life will greatly diminished. Incorporating the new study's findings into discussions with very elderly patients before starting them on RRT would seem a prudent thing to do.