Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes

Kidney in old age

Epidemiological studies have shown that chronic kidney disease (CKD) is a major health problem especially in an older population. Given the growing segment of the elderly population and the important implication of renal disease on health care, this review discusses the structural and functional changes of the ageing kidney and the underlying mechanisms of age-dependent injury. The implications of these changes in daily clinical practice and the management of CKD is also briefly overviewed.

Assisted peritoneal dialysis

Elderly patients are the largest and fastest growing group of patients with chronic kidney disease maintained on dialysis in the world. Because of advanced age and a heavy burden of comorbidities, the elderly are usually not candidates for kidney transplantation and are less likely to be offered peritoneal dialysis (PD). There is, however, growing evidence that the use of community nurses to assist with PD and the introduction of programs for assisted peritoneal dialysis (aPD) targeting these frail, elderly patients may enable more elderly patients to have their PD treatment at home. Suitable candidates for aPD are incident end-stage kidney disease patients preferring PD but unable to perform their own treatment because of comorbidities, physical disabilities, or psychosocial problems; prevalent, previous autonomous PD patients who have lost their independence because of advanced age or an increased burden of comorbidities; or prevalent hemodialysis (HD) patients switched from HD to aPD because of their own preference, failure of vascular access for HD, or an inability to tolerate HD. We believe that aPD in the future will prove to be a safe and feasible complementary alternative to in-center HD for the growing group of frail, elderly patients with end-stage kidney disease.

The epidemics of cardiovascular disease in elderly patients with chronic kidney disease--two facets of the same problem

There is increasing evidence that even mild renal dysfunction is a novel potent cardiovascular risk factor in the general elderly population. With more severe renal impairment, cardiovascular risk increases proportionately. This issue deserves attention, as chronic kidney disease (CKD) is predominantly a disease of the elderly, and the mean age of end-stage renal disease patients entering dialysis is growing constantly. In the dialysis population, when clinically significant cardiovascular disease (CVD) (particularly congestive heart failure) is present, survival is worse. Thus, every effort should be made to identify and treat cardiovascular risk factor in the early stages of CKD. However, elderly renal patients receive less proper cardiovascular therapy compared to non-renal subjects of the same age. This review deals briefly with the most significant data published in the last decade on CVD in elderly with CKD.

A meta-analysis of dialysis access outcome in elderly patients

BACKGROUND

Many authors report inferior patency rates of distal arteriovenous fistulas in elderly patients and others present contradictory results. A meta-analysis of available evidence was performed to assess (1) whether non-elderly adults have the same risk of forearm arteriovenous fistula failure as elderly patients with end-stage renal disease and (2) whether such a distal access has the same risk of failure as more proximal access procedures or grafts in elderly patients.

METHODS

A literature search was performed using the MEDLINE and SCOPUS electronic databases. The analysis involved studies that comprised subgroups of elderly patients and compared their outcomes with those of non-elderly adults. Articles comparing patency rates of radial-cephalic and proximal fistulas or grafts in elderly patients were also included. Thirteen relevant studies (all cohort observational studies, 11 retrospective) were identified and included in the final analysis.

RESULTS

The meta-analysis revealed a statistically significantly higher rate of radial-cephalic arteriovenous fistula failure in elderly patients compared with non-elderly adults at 12 (odds ratio [OR], 1.525; P = .001) and 24 months (OR, 1.357, P = .019). The primary radial-cephalic arteriovenous fistula failure rate was also in favor of the non-elderly adults (OR, 1.79; P = .012). Secondary analysis revealed a pooled effect in favor of the elbow brachiocephalic fistulas that was statistically significant (P = .004) compared with distal fistulas in elderly patients.

CONCLUSION

This meta-analysis found an increased risk of radial-cephalic fistula failure in elderly patients and significant benefit from the creation of proximal autologous brachiocephalic fistulas. If confirmed by further prospective studies, these differences should be considered when planning a vascular access in incident elderly patients.

The prevalence of symptoms in end-stage renal disease: a systematic review

Symptoms in end-stage renal disease (ESRD) are underrecognized. Prevalence studies have focused on single symptoms rather than on the whole range of symptoms experienced. This systematic review aimed to describe prevalence of all symptoms, to better understand total symptom burden. Extensive database, "gray literature," and hand searches were undertaken, by predefined protocol, for studies reporting symptom prevalence in ESRD populations on dialysis, discontinuing dialysis, or without dialysis. Prevalence data were extracted, study quality assessed by use of established criteria, and studies contrasted/combined to show weighted mean prevalence and range. Fifty-nine studies in dialysis patients, one in patients discontinuing dialysis, and none in patients without dialysis met the inclusion criteria. For the following symptoms, weighted mean prevalence (and range) were fatigue/tiredness 71% (12% to 97%), pruritus 55% (10% to 77%), constipation 53% (8% to 57%), anorexia 49% (25% to 61%), pain 47% (8% to 82%), sleep disturbance 44% (20% to 83%), anxiety 38% (12% to 52%), dyspnea 35% (11% to 55%), nausea 33% (15% to 48%), restless legs 30% (8%to 52%), and depression 27% (5%to 58%). Prevalence variations related to differences in symptom definition, period of prevalence, and level of severity reported. ESRD patients on dialysis experience multiple symptoms, with pain, fatigue, pruritus, and constipation in more than 1 in 2 patients. In patients discontinuing dialysis, evidence is more limited, but it suggests they too have significant symptom burden. No evidence is available on symptom prevalence in ESRD patients managed conservatively (without dialysis). The need for greater recognition of and research into symptom prevalence and causes, and interventions to alleviate them, is urgent.

Late referral – a major cause of poor outcome in the very elderly dialysis patient

BACKGROUND

The population of incident dialysis patients is progressively ageing and dialysis outcome is particularly poor in the elderly. There is little documentation whether late referral is more frequent in the very elderly (> or =75 years) as compared with non-elderly patients and whether it contributes, at least in part, to their particularly poor outcome.

METHODS

In a retrospective single center study we assessed all consecutive patients (n = 254) who had been admitted to haemodialysis between 1998 and 2001. Outcome in relation to the interval between the time of referral and start of dialysis was compared in very elderly and non-elderly patients. According to a previous analysis in our center major adverse outcome is seen in patients referred < or =8 weeks before the start of dialysis. For the present study this time interval was therefore operationally defined as 'late referral'.

RESULTS

Expectedly 1 year after start of dialysis mortality was higher (31%) in the very elderly compared with younger patients (19%). The interval between referral and first dialysis was less in patients > or =75 years (median interval 3.5 weeks) compared with patients <75 years (median 20.5 weeks; P = 0.007). The difference in 1 year mortality between timely (>8 weeks) vs late (< or =8 weeks) referral, however, was as high in the very elderly (42% vs 16%) as in the younger patients (34% vs 9%). The relative risk of death conferred by late referral was also not significantly different in the very elderly (RR 1.80) compared with the younger (RR 2.32) patient. Using multivariate analysis timing of referral proves to be an independent factor with regard to the outcome and time of survival.

CONCLUSIONS

We conclude that late referral is more frequent in the very elderly. Although the relative risk of death conferred by late referral is similar in the very elderly and non-elderly, due to higher frequency of late referral it accounts for a large proportion of excess mortality in the very elderly.

The impact of an out-reach clinic on referral of patients with renal impairment

BACKGROUND

Early diagnosis and prompt treatment of a number of renal diseases may delay renal failure, obviate the need for renal replacement therapy and reduce co-morbidity. The aim of this study was to examine the impact of out-reach renal clinics on patterns of referral of patients with renal impairment to a nephrologist.

METHODS

The number of patients with renal impairment was determined as defined by serum creatinine levels >150 micromol/l in three centres within a single NHS trust over two separate 1-week periods. None of the centres studied has a local nephrologist, however one centre (hospital A) has renal out-reach clinics, another is geographically close to a renal unit (hospital B), while the third unit (hospital C) has no nephrology presence and is geographically furthest from the renal unit. In addition, retrospective as well as follow-up data on the renal function of all patients with renal impairment was collected.

RESULTS

In hospital A, there was a lower proportion of patients with unreferred renal impairment than in the other two hospitals. Within the unreferred patient group there were significantly more patients whose renal function improved during the follow-up period. A considerable proportion of patients with documented deterioration in renal function remained unknown to nephrology services 6 months after initial presentation. Other than the presence of an onsite nephrology service, the only other factor found to be significantly different in those patients not referred to nephrologists was age: as in all three centres, those not referred were significantly older.

CONCLUSION

Inequity of access to renal services is an important obstacle to early referral of patients with impaired renal function. Out-reach renal services provide a model which significantly improves referral patterns.

Critical care nursing for older adults: pathophysiological and functional considerations

The aging of the population brings into health care practice, including ICUs, an increasing prevalence of people with chronic conditions with corresponding expectations of eventual decline in function. These age-related health problems, however, do not have a precise moment of onset, nor a single and unambiguous cause. By their nature, chronic conditions do not have an end that can be modified easily, and ordinarily, they are related to parameters other than physiology alone. Aged individuals often are distinguished as a medicalized cohort on the basis of sheer numbers of comorbidities and predisposition toward frequent hospitalizations, without regard for the potential for adaptation to life despite complex health factors. Some care providers, health economists, and bioethicists propose using the existence of chronic conditions and assumed physical decompensation asa valid basis for restricting individuals and groups, by means of rationing, from consideration for intensive care and treatment. In view of studies demonstrating that covert rationing of ICU resources to critically ill older patients already is taking place, there isa need to continue to examine institutional policies that permit care providers to act as gatekeepers, ostensibly with benign intent, but presumably without patients' knowledge or acceptance. On the other hand, there is evidence that older ICU patients do equally well as younger and middle-aged patients in terms of discharge from the hospital with subsequent recovery of function. Thus, age alone is not a useful marker for limiting access to ICUs. Rather, a comprehensive evaluation is the foundation for diagnostic accuracy and health care decision-making for older individuals. Assessment and maintenance of the older person's functional status are fundamental concerns of geriatric and critical care specialists. Evaluation of an individual's baseline abilities in physical, mental, social, and psychological spheres is necessary before limitation of care realistically can be considered. Intensive care unit hospitalizations for catastrophic or critical illness are not necessarily terminal events. Ongoing functional assessment will help to illuminate the impact of chronicity on an older person's capacity for self care, and may help to guide health care decision-making regarding use of critical care resources. Accordingly, assuring equitable access to essential intensive care services, devoid of concerns about age constraints, will help to ensure the autonomy that is central to older adults' achievement of a fulfilling and productive old age.