SEATTLE—A study by British investigators suggests that more older patients with end-stage renal disease (ESRD) should be educated about peritoneal dialysis (PD) and the potential benefits it may offer over hemodialysis (HD).

Edwina Brown, MD, Professor of Renal Medicine at Imperial College London, presented the latest findings from the BOLDE (Broadening Outcomes of Long-Term Dialysis in the Elderly) study at the 30th Annual Dialysis Conference here. The study is one of the first to compare HD and PD outcomes in the elderly. 

Previously published studies have shown patients aged 65 and older are less likely to start on PD than younger patients. However, few data are available regarding how older patients with multiple disabilities cope with different dialysis modalities or how these individuals arrive at their choice on dialysis modality.

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The BOLDE study compared health-related quality of life (QoL) for older patients on PD and HD and explored factors affecting patient decision-making and factors affecting patient choice. Dr. Brown and her colleagues compared 70 HD patients and 70 PD patients. In both groups, the mean age was 73 years and 70% were men. In the PD group, 23% lived alone compared with 27% of the HD group.

The mean number of months on dialysis was similar between the two groups (30.5 months for PD group vs. 31.4 months for the HD group) and both groups had similar levels of formal education. PD patients had a significantly better QoL than HD patients as indicated by scores on the Illness Intrusion Rating Scale. Intrusiveness was determined by assessing the extent to which the illness and/or treatment interferes with 13 life domains. PD patients had a significantly lower overall score of 22 compared with 26 for HD patients. This difference was due to HD patients experiencing significantly greater intrusion of their illness and/or their treatment on their health and diet compared to patients on PD.

“There is actually very little information about how older patients cope with dialysis treatment so these findings are significant,” Dr. Brown told Renal & Urology News.

The study also found that cognitive impairment, which Dr. Brown said often is overlooked in the elderly, is highly prevalent in dialysis patients aged 65 and older. Only two-thirds of subjects performed an executive function test (Trail Making Test B) within the expected range for their age and education. The investigators identified depression in about 20% of patients.

Depression was related to symptoms and comorbidities, and it was more common in female patients. The most common dialysis-related symptoms (dry mouth, dizziness, headaches, unsteadiness, taste changes) were less common in PD patients compared with HD patients, although leg swelling was more common in PD.

“Physicians really should consider home-base peritoneal dialysis for older patients because they appear to cope with it very well and it intrudes less into their life,” Dr. Brown said. “They can learn how to do the technique and it gives them independence, and of course it costs less [than in-center HD].”

Clinicians need to look at many factors when deciding on dialysis modality for ESRD patients aged 65 and older, such as physical and cognitive function, nutritional status, depression, social isolation, vision and hearing issues, and social support, Dr. Brown said. 

The use of PD in older adults is on the decline in England, where the study was conducted, as well as around the world. Yet, study findings suggest that many older adults may prefer PD over HD.

Some patients report liking that they could be treated at home because transportation was an issue and dialyzing at home is preferable to receiving treatment at a dialysis center three days a week and then returning home too exhausted to function. Dr. Brown noted that one patient involved in the study commented: “How the kidney disease and the dialysis affects me socially is as important to me as my medical treatment. Therefore, this research is useful for others to understand how we feel being on dialysis.” n