Whether dialysis is the best option for kidney failure and, if so, when to start may merit more careful consideration, according to a new study.
For older adults who were not healthy enough for a kidney transplant, starting dialysis when their kidney function fell below a certain threshold (rather than waiting) gave them about an extra week of life, Stanford Medicine researchers and their colleagues found.
Most critically, perhaps, they spent an average of two more weeks in hospitals or care facilities, in addition to the time spent on dialysis.
“Is that really what a 75- or 80-year-old patient wants to do?” asked Dr. Maria Montez Rath, a senior research engineer.
Montez Rath is the lead author of a study on dialysis, life expectancy, and time at home that will be published in Annals of Internal MedicineThe lead author is Dr. Manjula Tamura, professor of nephrology.
“For all patients, but particularly older adults, it’s really essential to understand the pros and cons,” Tamura said. “They and their doctors need to carefully consider whether and when to proceed with dialysis.”
Patients with kidney failure who are healthy enough for a transplant can receive a donated kidney, which will remove toxins and excess fluid from their blood. But that option isn’t available to many older adults who have other health conditions, such as heart or lung disease or cancer.
For such patients, doctors often recommend dialysis (a treatment that cleans the blood as healthy kidneys would) when patients progress to kidney failure. Patients are considered to have kidney failure when their estimated glomerular filtration rate (eGFR), a measure of kidney function, falls below 15.
Patients and their families sometimes assume dialysis is their only option or that it will significantly prolong life, Montez Rath said. “They often say yes to dialysis, without really understanding what that means.”
But patients can take medications instead of dialysis to control symptoms of kidney failure, such as fluid retention, itching and nausea, Tamura said. He added that dialysis has side effects, such as cramps and fatigue, and typically requires a three- to four-hour visit to a clinic three times a week.
“It’s a fairly intensive therapy that involves a major change in lifestyle,” he said.
Life expectancy and time at home
Researchers conducted the study to quantify what dialysis means for older adults who are not eligible for a transplant: whether and how much it prolongs life, along with the relative number of days they spend in an inpatient facility such as a hospital, nursing home or rehabilitation center.
The team evaluated medical records from 2010 to 2018 for 20,440 patients (98 percent of them men) in the U.S. Department of Veterans Affairs. Patients were 65 years or older, had chronic kidney disease, were not being evaluated for transplant, and had an estimated glomerular filtration rate (GFR) of less than 12.
Simulating a randomized clinical trial using electronic medical records, they divided patients into groups: those who started dialysis immediately and those who waited at least a month. Over three years, about half of the patients in the waiting group never started dialysis.
Patients who started dialysis immediately lived an average of nine days longer than those who waited, but spent 13 more days in an inpatient facility. Age made a difference: Patients aged 65 to 79 who started dialysis immediately lived an average of 17 fewer days while spending 14 more days in an inpatient facility; patients aged 80 or older who started dialysis immediately lived an average of 60 days longer but spent 13 more days in an inpatient facility.
Patients who never underwent dialysis died on average 77 days earlier than those who started dialysis immediately, but spent 14 more days at home.
“The study shows us that if you start dialysis right away, you may survive longer, but you’ll spend a lot of time on dialysis and you’ll be more likely to need to be hospitalized,” Montez Rath said.
Tamura noted that doctors sometimes recommend dialysis because they want to offer hope to patients or because the downsides of the treatment haven’t always been clear. But the study indicates that doctors and patients might want to wait until the eGFR drops even further, Tamura said, and should consider symptoms along with personal preferences before starting dialysis.
“Each patient has their own goals,” she said. “For some, having this dialysis option is a blessing, and for others it can be a burden.”
It might be helpful, he added, for doctors to describe dialysis for older and frail adults as a palliative treatment, the primary goal of which is to relieve symptoms.
“Dialysis is often presented to patients today as a choice between life and death,” he said. “When presented this way, patients have no room to consider whether the treatment is in line with their goals and tend to overestimate the benefits and comfort they might experience. But when treatment is presented as symptom relief, patients can more easily understand that there are trade-offs.”
*The illustration must be credited to Emily Moskal/Stanford Medicine. It may be used for editorial purposes only and not for commercial, promotional, endorsement, advertising or marketing purposes. It may only be used in conjunction with a story about the research described in this article.