Dialysis can prolong life, but it is not for everyone with end-stage kidney disease, especially for seriously ill older patients, according to Susan P.Y. Wong, MD, MS, an associate professor in the division of nephrology at the University of Washington, Seattle.
“Most patients don’t get healthier after dialysis, they tend to get sicker,” said Dr Wong, who spoke at a session at the National Kidney Foundations 2023 Spring Clinical Meetings titled Interprofessional: Kidney Failure in the Older Adult: All You Wanted to Know but Were Afraid to Ask!
Patients treated with dialysis are much more likely to be hospitalized and receive an intensive procedure. With respect to end-of-life care, these patients are less likely to receive hospice and palliative measures and more likely to die in the hospital.
“Life expectancy is woefully limited for older patients starting dialysis,” Dr Wong said. “Many of these patients also experience significant symptom burden, functional and cognitive decline, and frequent hospitalization and institutionalization after starting therapy.” Only about 10% are able to remain facility-free after dialysis initiation.
Older patients with progressive kidney disease often might be better off with conservative kidney management. This approach is more than just not doing dialysis. It is a planned, holistic, and patient-centered approach to caring for patients who have chosen not to pursue renal replacement therapy.
Conservative kidney management is focused primarily on enhancing quality of life for patients through intensive symptom management, advance care planning, and psychosocial support. “My own research and that of others have shown that while some patients choose not to receive kidney replacement therapy, they also do not receive conservative kidney management after they have made this decision,” Dr Wong said. “There is a need to understand and address barriers to accessing and delivering high quality conservative kidney management.”
Understanding what is likely to occur during the remainder of their life on dialysis is important to patients and supports shared decision-making between patients and their physicians. “Having all the prognostic information can help patients make the best decision about dialysis,” she said. Yet, adults aged 75 years and older are the fastest growing group of patients in the United States starting dialysis. More older patients in the United States opt for dialysis compared with other countries. Communication breakdown is one reason for this and one that clinicians can readily address.
Bernard G. Jaar, MD, MPH, a clinical director in the division of nephrology at Johns Hopkins University School of Medicine in Baltimore, Maryland, who chaired the session, said there is an increasing number of older adult patients with kidney failure who may not be receiving optimal care. Many have survived cardiovascular complications or even cancer and now face kidney failure.
“Often, they are referred late to a nephrologist and are not prepared to make an informed decision about their kidney failure,” Dr Jaar said. “They typically have a high burden of comorbidities and unfortunately, too often, they are pushed to starting dialysis, particularly in-center hemodialysis, because it may be the easiest thing to do.”
Studies show that starting dialysis in patients over 75 with comorbidities often does not restore their quality of life or even improve patient satisfaction with their care. “Often these patients with kidney failure are not well-informed about their treatment options,” Dr Jaar said. “Often these patients are not kidney transplant candidates, and dialysis is not necessarily the best option.”
Conservative kidney management and renal replacement therapy should be part of the conversation between the patient and their caregivers, according to Dr Jaar. To facilitate this conversation, early referral to nephrology is helpful, providing time to establish a patient-physician relationship, provide the needed education, and for the patient and caregiver to make an informed decision.
Christine Corbett, DNP, Associate Chief Nursing Officer for Advanced Practice Providers Nurse Practitioner-Nephrology and Palliative Care, Kansas City, Missouri, said the biggest challenge is the lack of communication regarding prognosis and shared decision-making with patients facing difficult decisions, such as whether to initiate dialysis. “Another challenge is lack of advance care planning for patients with CKD, which should be completed early in CKD so providers understand their wishes.”
Increasing advance care planning in the CKD clinic should be conducted when patients have a change in prognosis or hospitalization, Corbett said. Additional education is needed to increase awareness of conservative kidney management as an option.