Clinical outcomes of elderly patients undergoing chronic peritoneal dialysis: experiences from one center and a review of the literature

Outcomes of elderly peritoneal dialysis patients: 65-74 years old versus ≥ 75 years old

OBJECTIVE

To analyze the clinical data of elderly patients with peritoneal dialysis (PD) and compare patient and technique survival rates between Group 1 (65-74 years old) and Group 2 (≥75 years old).

METHODS

This retrospective study enrolled 296 elderly patients (≥65 years old) on maintenance PD who were admitted to the Peritoneal Dialysis Center of the Second Hospital of Soochow University. The patients were categorized by outcome into ongoing PD, changed to hemodialysis, renal recovery dialysis stopped, or death groups. The patients were divided into Group 1 (65-74 years old) and Group 2 (≥75 years old). Patient survival and technique survival rates were calculated by the Kaplan-Meier method. Factors associated with patient survival were analyzed using the Cox regression model.

RESULTS

There were 176 (59.5%) subjects in Group 1 and 120 (40.5%) subjects in Group 2. The primary causes of death were cardiovascular events, peritonitis, and other infections. The patient survival rates at 1, 3, and 5 years were 91.2%, 68.0%, and 51.3% in Group 1 and 76.8%, 37.5%, and 17.6% in Group 2 (p < 0.001, HR 0.387, 95% CI 0.282-0.530). There was no statistically significant difference in the technique survival rate between the two groups (p = 0.54).

CONCLUSION

The elderly PD patients in this cohort mostly died from cardiovascular events, with a higher patient survival rate in Group 1 and similar technique survival in both groups. Older age, lower prealbumin, higher creatinine, not being on activated vitamin D, and high Charlson's comorbidity index (CCI) score were independent risk factors for death.

Microbiology and Outcome of Peritoneal Dialysis-Related Peritonitis in Elderly Patients: A Retrospective Study in China

Objective

The number of elderly patients on peritoneal dialysis (PD) has rapidly increased in the past few decades. We sought to explore the microbiology and outcomes of peritonitis in elderly PD patients compared with younger PD patients.

Methods

We conducted a retrospective study to analyze the clinical characteristics, causative organism distribution, and outcome of all PD patients who developed peritonitis between September 1, 2014 and December 31, 2020, from Second Xiangya Hospital, Central South University, China. Patients who experienced peritonitis were separated into elderly and younger groups. The elderly was defined as ≥ 65 years old at the initiation of PD.

Results

Among 1,200 patients, 64(33.9%) in elderly (n = 189) and 215 (21.3%) in younger (n = 1,011) developed at least one episode of peritonitis. A total of 394 episodes of peritonitis occurred in 279 patients. Of these, 88 episodes occurred in 64 elderly patients, and 306 episodes occurred in 215 younger patients. Gram-positive bacteria were the main causative organisms in elderly and younger patients (43.2% and 38.0%, respectively). Staphylococcus and Escherichia coli were the most common gram-positive and gram-negative bacteria, respectively. Fungal peritonitis in elderly patients was higher compared with younger patients (χ2 = 6.55, P = 0.01). Moreover, Acinetobacter baumannii (χ ²=9.25, P = 0.002) and polymicrobial peritonitis (χ ² = 6.41, P = 0.01) in elderly patients were also significantly higher than that in younger patients. Additionally, elderly PD patients had higher peritonitis-related mortality than younger patients (χ ² = 12.521, P = 0.000), though there was no significant difference in catheter removal between the two groups. Kaplan-Meier analysis showed that cumulative survival was significantly lower in elderly patients than younger patients (log rank = 7.867, p = 0.005), but similar technical survival in both groups (log rank = 0.036, p = 0.849).

Conclusions

This retrospective study demonstrated that elderly PD patients were more likely to develop Acinetobacter baumannii, fungal and polymicrobial peritonitis than younger PD patients. In addition, peritonitis-related mortality was significantly higher in elderly patients, whereas peritonitis-related catheter removal was comparable between elderly and younger PD patients. Understanding microbiology and outcome in elderly patients will help to reduce the incidence of PD-associated peritonitis and improve the quality of life.

Outcomes of peritoneal dialysis in elderly vs non-elderly patients: A systemic review and meta-analysis

OBJECTIVES

Several studies have compared outcomes of peritoneal dialysis (PD) between elderly and non-elderly patients but with variable results. We hereby designed this review to compare mortality, peritonitis, and technique survival between elderly and non-elderly patients on PD.

METHODS

PubMed, Embase, and Google Scholar were searched for studies comparing outcomes of PD between elderly and non-elderly patients. The last search date was 14th July 2021.

RESULTS

Fourteen studies were included. 12 studies defined the elderly as ≥65 years of age and these were included in the meta-analysis. Pooled analysis of crude (RR: 2.45 95% CI: 1.36, 4.40 I2 = 97% p = 0.003) and adjusted data (HR: 2.80 95% CI: 2.45, 3.09 I2 = 0% p<0.00001) indicated a statistically significant increased risk of mortality amongst elderly patients as compared to non-elderly patients. Meta-analysis of four studies demonstrated a statistically significant increased risk of peritonitis in the elderly (RR: 1.56 95% CI: 1.18, 2.07 I2 = 76% p = 0.002). Pooled analysis demonstrated no statistically significant difference in technique survival between the two groups (RR: 0.95 95% CI: 0.86, 1.05 I2 = 86% p = 0.32).

CONCLUSION

Elderly patients on PD have a significantly increased risk of mortality as compared to non-elderly patients. The risk of peritonitis is also significantly increased in older adults but the increased age has no impact on technique survival. Further studies are needed to strengthen our conclusions.

Peritoneal dialysis in older adults: Evaluation of clinical, nutritional, metabolic outcomes, and quality of life

The number of older adults requiring dialysis is increasing worldwide, whereas the use of peritoneal dialysis (PD) in this population is lower with respect to younger patients, despite the theoretical advantages of PD respect to hemodialysis. This is most likely due to the concern that older patients may not be able to correctly and safely manage PD.We aimed to prospectively compare clinical, nutritional and metabolic outcomes and measures of quality of life between younger (<65 years old) and older (≥65 years old) patients on PD.PD patients were enrolled and divided into 2 groups according to age (Group A < 65 years, Group B ≥ 65 years). Clinical and instrumental parameters, and quality of life were evaluated at baseline (start of PD) (T0) and at 24 months (T1). Technique survival, mortality, total number of hospitalizations, and the index of peritonitis (episodes of peritonitis/month) were also evaluated.Fifty-one patients starting PD were enrolled. Group A included 22 patients (48.7 ± 8.3 years), and Group B consisted of 29 patients (74.1 ± 6.4 years). At baseline, the 2 groups showed no differences in cognitive status, whereas Group A showed higher total cholesterol (P = .03), LDL (P = .03), and triglycerides (P = .03) levels and lower body mass index (P = .02) and carotid intima media thickness (P < .0001) with respect to Group B. At T1 Group B showed, compared to baseline, a significant reduction in albumin (P < .0001) and phosphorus (P = .045) levels, while no significant differences on body composition, technique survival, total number of hospitalizations, index of peritonitis, and quality of life indices were observed.Our data do not show clinically relevant barriers to use PD in older adult patients, supporting its use in this population. Nutritional and metabolic parameters should be carefully monitored in older PD patients.

Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis

BACKGROUND

Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known.

METHODS

Retrospective cohort study of patients ≥66 years who initiated chronic dialysis in 2000-2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3-6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes.

RESULTS

Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p < 0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65-0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42-3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77-0.82).

CONCLUSION

In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.

Peritoneal dialysis in centenarian patients: no age limitation?

BACKGROUND

The majority of dialysis patients are elderly, and the trend towards even more elderly people with end-stage renal disease (ESRD) will further determine the dialysis field in the future.

METHOD

If these elderly ESRD patients do not opt for conservative ESRD care, they may still qualify for peritoneal dialysis (PD), which may be assisted or unassisted.

RESULTS

Although they may be more frail and have a greater co-morbidity burden compared to their younger counterparts, elderly patients with ESRD may still be able to maintain a good functionality level with adequate quality of life by performing PD, which may be assisted (treatment performed or supported e.g. by partner or nurse) or unassisted (without support). PD may indeed further contribute to maintaining autonomy, and enhance quality of life compared to in-center conventional hemodialysis. In order to illustrate this strategy, we hereby describe a centenarian patient with ESRD who received assisted PD successfully.

CONCLUSIONS

With appropriate management and infrastructure, (very) high age is not a contra-indication for PD.

Results in Assisted Peritoneal Dialysis: A Ten-Year Experience

Background/Aims. Peritoneal dialysis is a successful renal replacement therapy (RRT) for old and dependent patients. We evaluated the clinical outcomes of an assisted peritoneal dialysis (aPD) program developed in a Portuguese center. Methods. Retrospective study based on 200 adult incident patients admitted during ten years to a PD program. We included all 17 patients who were under aPD and analysed various parameters, including complications with the technique, hospitalizations, and patient and technique survival. Results. The global peritonitis rate was lower in helped than in nonhelped patients: 0.4 versus 0.59 episodes/patient/year. The global hospitalization rate was higher in helped than in nonhelped patients: 0.67 versus 0.45 episodes/patient/year (p = NS). Technique survival in helped patients versus nonhelped patients was 92.3%, 92.3%, 83.1%, and 72.7% versus 91.9%, 81.7%, and 72.1%, and 68.3%, at 1, 2, 3, and 4 years, respectively (p = NS), and patient survival in helped patients versus nonhelped patients was 93.3%, 93.3%, 93.3%, and 74.7% versus 95.9% 93.7%, 89%, and 82% at 1, 2, 3, and 4 years, respectively (p = NS). Conclusions. aPD offers an opportune, reliable, and effective home care alternative for patients with no other RRT options.

Elderly Peritoneal Dialysis Compared with Elderly Hemodialysis Patients and Younger Peritoneal Dialysis Patients: Competing Risk Analysis of a Korean Prospective Cohort Study

The outcomes of peritoneal dialysis (PD) in elderly patients have not been thoroughly investigated. We aimed to investigate the clinical outcomes and risk factors associated with PD in elderly patients. We conducted a prospective observational nationwide adult end-stage renal disease (ESRD) cohort study in Korea from August 2008 to March 2013. Among incident patients (n = 830), patient and technical survival rate, quality of life, and Beck’s Depression Inventory (BDI) scores of elderly PD patients (≥65 years, n = 95) were compared with those of PD patients aged ≤49 years (n = 205) and 50~64 years (n = 192); and elderly hemodialysis (HD) patients (n = 315). The patient death and technical failure were analyzed by cumulative incidence function. Competing risk regressions were used to assess the risk factors for survival. The patient survival rate of elderly PD patients was inferior to that of younger PD patients (P<0.001). However, the technical survival rate was similar (P = 0.097). Compared with elderly HD patients, the patient survival rate did not differ according to dialysis modality (P = 0.987). Elderly PD patients showed significant improvement in the BDI scores, as compared with the PD patients aged ≤49 years (P = 0.003). Low albumin, diabetes and low residual renal function were significant risk factors for the PD patient survival; and peritonitis was a significant risk factor for technical survival. Furthermore, low albumin and hospitalization were significant risk factors of patient survival among the elderly. The overall outcomes were similar between elderly PD and HD patients. PD showed the benefit in BDI and quality of life in the elderly. Additionally, the technical survival rate of elderly PD patients was similar to that of younger PD patients. Taken together, PD may be a comparable modality for elderly ESRD patients.

Evaluation of nutritional status with different methods in geriatric hemodialysis patients: impact of gender

PURPOSE

This study investigated the frequency of malnutrition in geriatric hemodialysis patients according to biochemical, anthropometric, bioelectrical impedance analysis (BIA), modified quantitative subjective global assessment (MQSGA), and geriatric nutritional risk index (GNRI) methods, and the effect of gender on these different parameters.

METHODS

A total of 160 chronic hemodialysis patients (older than 65 years old) were included in this study. There were 82 males (51.2 %) and mean age was 72.8 ± 6.1 years. Nutritional status of patients was evaluated by using serum albumin, body mass index (BMI), triceps skinfold (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), calf circumference (CC), BIA, MQSGA, and GNRI.

RESULTS

The prevalence of malnutrition according to the aforementioned methods were as following: MAC 62.5 %, MQSGA 60 %, MAMC 50 %, CC 43.1 %, TSF 39.4 %, body fat percentage 33.8 %, albumin 29.1 %, GNRI 15 %, and BMI 8 %. While malnutrition was found to be more prevalent among women according to MQSGA, TSF, and body fat percentage (p = 0.008, p < 0.001, p = 0.042, respectively), it was more frequent in men when we used MAC and MAMC (p = 0.012, p < 0.001, respectively).

CONCLUSIONS

Our data indicated that while there was a difference in malnutrition prevalence between female and male geriatric hemodialysis patients according to MQSGA, TSF, MAC, and body fat percentage, there was no difference between genders in terms of malnutrition prevalence according to GNRI, albumin, BMI, and CC.

Clinical outcome of elderly peritoneal dialysis patients with assisted care in a single medical centre: a 25 year experience

AIM

Peritoneal dialysis (PD) is an alternative treatment for elderly patients with end-stage renal disease (ESRD). In Taiwan, non-professional personnel are employed to provide assisted care for elderly patients. Whether assisted care is appropriate for elderly patients is unknown. The aim of this paper is to evaluate the outcomes of assisted care in a single centre.

METHODS

This is a retrospective cohort study in a single medical centre. The outcomes were derived from the assessment of patient survival, technique survival and peritonitis incidence between self-care patients and assisted-care patients.

RESULTS

From 1984 to 2010, there were 138 elderly PD patients at Taichung Veterans General Hospital, of which 70% were assisted-care patients and 30% self-care patients. The mean duration of PD survival was 49.2 months in self-care patients, which was significantly longer than the 17.0 months of assisted-care patients (P < 0.05). Using the multivariate Cox proportion regression model to adjust for risk factors, it was found that self-care patients had a lower risk in both patient survival (Hazard Ratio 0.15; 95% confidence interval (CI) 0.2-0.94, P < 0.05) and technique survival (Hazard ratio; 0.11, 95% CI 0.1-0.9, P < 0.05). Fluid overloading was the major cause of technique failure in assisted-care patients. Type of assistance was not a risk factor for PD-related peritonitis.

CONCLUSION

Our elderly assisted care had patients had a poorer survival and technique survival rates than those of the self-care patients. We argue that this is because early recognition of medical deterioration and early medical intervention are necessary for a better outcome for elderly PD patients.

Novel predictors of peritonitis-related outcomes in the BRAZPD cohort

INTRODUCTION

Peritonitis remains the main cause of peritoneal dialysis (PD) technique failure worldwide, despite significant reductions in infection rates observed over the past decades. Several studies have described risk factors for peritonitis, technique failure and mortality. However, there are scarce data regarding predictors of complications during and after a peritonitis episode. The aim of our study was to analyze predictors of peritonitis-related outcome in the Brazilian Peritoneal Dialysis study (BRAZPD) cohort.

METHODS

All adult incident patients recruited in the BRAZPD Study between December 2004 and October 2007, who remained at least 90 days on PD and presented their first peritonitis episode (n = 474 patients) were included in the study. The endpoints analyzed were non-resolution, death due to a peritonitis episode and long-term technique survival after a peritonitis episode.

RESULTS

In the multivariable regression, non-resolution was independently associated with older age (odds ratio (OR) 1.02; p < 0.01), collagenosis as the primary renal disease (OR 4.6; p < 0.05) and Pseudomonas spp as etiological agent (OR 2.9; p < 0.05). Patients who were transferred from APD to CAPD during peritonitis therapy presented a higher risk of non-response (OR 2.5; p < 0.05). The only factor associated with death during a peritonitis episode was older age (OR 1.04; p < 0.05). Exposure to vancomycin and male gender were the independent predictors of long-term technique failure (OR 2.2; p < 0.01).

CONCLUSION

Apart from confirming previous observations of the negative impact of older age and Pseudomonas spp peritonitis on outcomes, we observed that collagenosis may negatively impact response to treatment and exposure to vancomycin may possibly reduce long-term technique survival. It is important to emphasize that the association of vancomycin with technique failure does not prove causality. These findings shed light on new factors predicting outcome when peritonitis is diagnosed.

Clinical outcomes in elderly patients on chronic peritoneal dialysis: a retrospective study from a single center in china

OBJECTIVES

We aimed to evaluate clinical outcomes and identify the predictors of mortality in elderly patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

This retrospective cohort study included all incident CAPD patients treated at our center from 2006 to 2009. Demographic and clinical data on initiation of CAPD and clinical events during the study period were collected. Survival probabilities were generated using the Kaplan-Meier method, and risk factors for mortality were evaluated using Cox proportional hazards models.

RESULTS

Of 805 patients on CAPD, the elderly group (≥65 years; mean age: 71.3 ± 4.3 years) consisted of 148 patients, and the younger group (<65 years; mean age: 43.1 ± 12.2years) consisted of 657 patients. The 1-, 2-, 3-, and 5-year patient survival rates were 97%, 92%, 88%, and 73% for the younger group, and 79%, 67%, 56%, and 30% for elderly group. The patient survival rates were significantly lower for the elderly group than for the younger group (p = 0.000). However, technique survival did not significantly differ between the groups (p = 0.559). In the patients overall, the independent predictors of death were old age (p = 0.003), diabetes (p = 0.000), cardiovascular disease (p = 0.006), lower hemoglobin (p = 0.010), and lower serum albumin (p = 0.024). Mortality in the elderly patients was associated with advanced age [relative risk (RR): 1.088; 95% confidence interval (CI): 1.027 to 1.153; p = 0.004], diabetes (RR: 2.064; 95% CI: 1.236 to 3.445; p = 0.006), and lower serum albumin (RR: 0.940; 95% CI: 0.897 to 0.985; p = 0.010).

CONCLUSIONS

The elderly patients on CAPD experienced technique survival comparable with that of younger patients, but their patient survival was lower. In elderly patients, mortality was determined predominantly by greater age, diabetes, and lower serum albumin. Our results indicate that chronic peritoneal dialysis is a viable dialysis option for elderly patients with end-stage renal disease. Better management of hypoalbuminemia and comorbid conditions might improve survival in elderly PD patients.

Clinical outcomes of peritoneal dialysis patients transferred from hemodialysis: a matched case-control study

OBJECTIVE

Our study aimed to evaluate clinical outcomes of patients transferred to peritoneal dialysis (PD) because of complications related to hemodialysis (HD). ♢

METHODS

In a 1:2 matched case-control study, we compared patient and technique survival between patients initially treated with HD for at least 3 months and then transferred to PD (transfer group) and patients started on and continuing with PD (no-transfer group). ♢

RESULTS

All baseline characteristics except for initial residual urinary output were comparable between the groups. Compared with patients in the transfer group, patients in the no-transfer group had a higher initial daily residual urinary output [850 mL (range: 600 - 1250 mL) vs 0 mL (range: 0 - 775 mL/d), p = 0.000]. The main reasons for transfer to PD were vascular access problems and cardiovascular disease. Patient survival and technique failure rates did not significantly differ between the groups (p > 0.05). The 1-, 3-, and 5-year patient survival rates were 80.0%, 53.7%, and 27.6% in the transfer group and 89.7%, 60.2%, and 43.1% in the no-transfer group. Age (per 10 years) and serum albumin were independent risk factors for long-term survival in PD patients. Relative risk of either death or technique failure was not significantly increased in patients transferred from HD. ♢

CONCLUSIONS

Patients who transferred to PD after failing HD had outcomes on PD similar to those for patients who started with and were maintained on PD. Age (per 10 years) and serum albumin were independent risk factors for long-term survival in PD patients.

Renal replacement therapy in the elderly population

ESRD has become an important problem for elderly patients. The segment of the ESRD population age 65 years or older has grown considerably, and this growth is expected to accelerate in coming years. Nephrologists caring for the elderly with advanced kidney disease will encounter patients with comorbid conditions common in younger patients, as well as physical, psychological, and social challenges that occur with increased frequency in the aging population. These challenging factors must be addressed to help inform decisions regarding the option to initiate dialysis, the choice of dialysis modality, whether to pursue kidney transplantation, and end-of-life care. This article will highlight some common problems encountered by elderly patients with ESRD and review data on the clinical outcomes of elderly patients treated with different modalities of dialysis, outcomes of kidney transplantation in the elderly, and nondialytic management of CKD stage 5.

Elderly dialysis patients: analysis of factors affecting long-term survival in 4-year prospective observation

Purpose

To assess factors influencing the long-term survival of elderly dialysis patients.

Methods

The study group consisted of 51 prevalent dialysis patients aged over 70 years (32 F and 19 M, all caucasians), who had been on a chronic hemodialysis (27) or peritoneal dialysis program (24) for at least 2 months; median age was 77 years, median time on dialysis before inclusion was 16 months, and median residual diuresis was 600 ml. The patients were prospectively followed up to 4 years, and an analysis of factors affecting survival was performed.

Results

Thirteen patients from the initial cohort of 51 (25.5 %) survived the whole 48-month observation period: 10 HD patients (37 %) and 3 PD patients (12.5 %). Annual mortality rate was 28.2 %: 37.4 % on PD vs. 20.9 % on HD. The dialysis modality had a significant impact on patients’ survival (p = 0.049; Cox F-test). The independent mortality risk factors in the Cox proportional hazard regression model were higher plasma pro-atrial natriuretic peptide (pro-ANP) (p = 0.006), lower residual diuresis (p = 0.048), and lower systolic blood pressure (BP) value (p = 0.039).

Conclusions

Paramount for the survival of the elderly on dialysis is adequate extracellular volume control. Residual renal function is a protective factor for the survival of elderly HD patients. This observation is novel, not previously reported in an elderly dialysis population.

Risk factors for mortality in stable peritoneal dialysis patients

BACKGROUND

The mortality rates of end-stage renal disease patients have significantly declined over the past decade. However, there are few reports on the risk factors for mortality in stable peritoneal dialysis (PD) patients who survive for a considerable time.

PATIENTS AND METHODS

We reviewed the medical records and identified all adult patients who received PD between April 2001 and March 2009 in our institution. The total cohort was 550 patients. Among these patients, 383 patients were enrolled as stable PD patients.

RESULTS

The cumulative survival of the stable PD patients was 91.6% at 3 years and 78.7% at 5 years. On univariate analysis, old age (≥65 years of age), hypoalbuminemia (<35 g/L), log C-reactive protein (CRP) (≥0.84), phosphorus (<1.13 mmol/L), statin, icodextrin, and the Davies index were associated with mortality for all PD patients. Old age, hypoalbuminemia, log CRP, phosphorus, the residual renal function (RRF) (≤4 mL/min/1.73 m2) at 24 months, renin-angiotensin system blockade, icodextrin, and the Davies index were associated with mortality for the stable PD patients. Multivariate analysis showed that, among the variables, age, log CRP, phosphorus, initial RRF, and the Davies index were associated with mortality for all PD patients. In stable PD patients, age, log CRP, phosphorus, RRF at 24 months, and the Davies index were associated with mortality.

CONCLUSION

Initial high RRF combined with the RRF preservation, maintenance of proper phosphorus, control of inflammation, and proper management of comorbidities may help to improve the survival of PD patients including stable PD patients.

Clinical practices and outcomes in elderly hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND AND OBJECTIVES

Demand for hemodialysis among elderly patients is increasing worldwide. Although clinical care of this high-risk group is complex and challenging, no guidelines exist to inform hemodialysis practices. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to assess dialysis practices and associated outcomes among elderly versus younger patients on chronic in-center hemodialysis in 12 countries.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Clinical characteristics, dialysis practices, and outcomes of elderly versus younger patients were compared among participants in four DOPPS regions in 2005 through 2007.

RESULTS

Although participant mean age increased over time in all DOPPS countries, the percentage of elderly varied widely. Overall, comorbidities and malnutrition were more common in the elderly. Fistulae were used less frequently among elderly versus younger patients in Europe and North America but not in Australia, New Zealand, and Japan. No difference in treatment time was observed between elderly and younger patients after normalizing for body weight. In all regions, ultrafiltration rates were lower among elderly patients. Elderly patients reported poorer quality of life with respect to the physical but not mental component scores. Mortality risk was three- to sixfold higher in the elderly group, whereas causes of death overall were similar for elderly and younger patients.

CONCLUSIONS

Elderly patients represent a different proportion of DOPPS participants across countries, possibly reflecting differences in policies and clinical practices. In general, hemodialysis practices in the elderly reflected each region's clinical patterns, with some variation by age group depending upon the practice.

Compared with younger peritoneal dialysis patients, elderly patients have similar peritonitis-free survival and lower risk of technique failure, but higher risk of peritonitis-related mortality

BACKGROUND

The number of elderly patients with end-stage kidney disease (ESKD) is increasing worldwide, but the proportion of elderly patients commencing peritoneal dialysis (PD) is falling. The reluctance of elderly ESKD patients to consider PD may be related to a perception that PD is associated with greater rates of complications. In the present study, we compared outcomes between younger and older PD patients.

METHODS

Using Australia and New Zealand Dialysis Registry data, all adult ESKD patients commencing PD between 1991 and 2007 were categorized into under 50, 50 - 64.9, and 65 years of age or older groups. Time to first peritonitis, death-censored technique failure, and peritonitis-associated and all-cause mortality were evaluated by multivariate Cox proportional hazards model analysis.

RESULTS

Of the 12 932 PD patients included in the study, 3370 (26%) were under 50 years of age, 4386 (34%) were 50 - 64.9 years of age, and 5176 (40%) were 65 years of age or older. Compared with younger patients (<50 years), elderly patients (≥ 65 years) had a similar peritonitis-free survival and a lower risk of death-censored technique failure [hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.79 to 0.93], but they had higher peritonitis-related (HR: 2.31; 95% CI: 1.68 to 3.18) and all-cause mortality (HR: 2.90; 95% CI: 2.60 to 3.23).

CONCLUSIONS

Not unexpectedly, elderly patients have higher peritonitis-related and all-cause mortality, which is likely a consequence of a greater prevalence of comorbid disease. However, compared with younger patients, elderly patients have superior technique survival and similar peritonitis-free survival, suggesting that PD is a viable renal replacement therapy in this group of patients.

Hospital admissions in elderly patients on chronic hemodialysis

BACKGROUND

The purpose of this study was to determine whether number of hospital admissions per patient per year (n/[pt-yr]) and hospital days per patient per year (d/[pt-yr]) differ between elderly and younger patients on chronic hemodialysis (HD).

PATIENTS AND METHODS

In a retrospective cohort analysis of incident HD patients in one dialysis unit over 15 years, we compared 166 HD patients older than 70 years (77.1 ± 4.7 yrs) at the onset of HD (group A) and 216 patients younger than 70 years both at onset (57.1 ± 7.6 yrs) and at the end of the HD period (group B). Eighty (48.2%) of group A and 141 (65.3%) patients of group B had diabetes mellitus.

RESULTS

No differences were noted in the overall hospitalization rate, presented as mean, {95% Confidence interval} (group A 2.40 {2.04-2.75}, group B 2.03 {1.89-2.16} n[pt-yr]) and days/[pt-year] (group A 33.6 {25.3-41.8}, group B 24.1 {18.9-29.23}). Group A had higher number of hospitalization days (P = 0.012) for surgery or trauma and higher rate (P = 0.045) and days (P = 0.041) of hospitalization for miscellaneous causes, primarily pulmonary disease, or malignancy. Among diabetic patients, group A had only a greater number of hospital days for cardiac disease (P = 0.050). Among patients without diabetes, group A had a higher number for hospital days for surgery or trauma (P = 0.027). All other univariate comparisons were not significant. Multiple linear regression identified comorbidity, quantified by the Charlson index, Caucasian race and poor compliance with the HD schedule as predictors of admission rate and days per year for vascular access issues and comorbidity, poor compliance, and advanced age at onset of HD as predictors of admission for causes other than vascular access related.

CONCLUSION

Hospitalizations, which affect quality of life, differ little between elderly and younger patients on HD. Therefore, hospitalizations do not constitute an argument for restricting access to HD to elderly patients.

Prognostic Survival Factors in Elderly Renal Failure Patients Treated with Peritoneal Dialysis: A Nine-Year Retrospective Study

Background

Few studies specifically investigating elderly patients on peritoneal dialysis (PD) have been conducted and great uncertainty remains on the factors involved in the vital prognosis. The objective of this study was to describe our population of patients aged 75 years or older at the time PD was initiated and to study their survival in terms of the relevant nephro-geriatric criteria inventoried at the beginning of treatment.

Methods

We retrospectively analyzed the data of all the elderly patients that began first-line PD in our center between 1 January 1997 and 31 July 2006 ( n = 112).

Results

Mean duration of survival on PD was 19.6 ± 13.9 months; by the end of the study 87 patients had died and 7 had been transferred to hemodialysis. The Cox model multivariate analysis of survival allowed us to select 5 independent predictive variables that had a considerable impact on survival: absence of nephrologic care before dialysis, associated comorbidities (Charlson Comorbidity Index), loss of physical and/or mental autonomy (AGGIR group), and polymedication. Above and beyond the weight of these clinical variables, institutionalization or, more generally, social isolation was a determining factor for the duration of survival in PD.

Conclusion

Any patient considered for peritoneal dialysis should be evaluated by a multidisciplinary team in collaboration with geriatric specialists for both the overall medical situation and the social and family environment.