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Khatri P, Davenport A. Dialysis for older adults: why should the targets be different? J Nephrol 2024; 37:841-850. [PMID: 38180729 PMCID: PMC11239777 DOI: 10.1007/s40620-023-01835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/18/2023] [Indexed: 01/06/2024]
Abstract
The number of patients aged > 75-years treated by dialysis continues to increase, particularly in developed countries. Haemodialysis is a well-established treatment with national and international clinical guidelines designed to provide patients with optimal treatment. However, these were developed when the dialysis population was younger, and less co-morbid. This change in patient demographics questions whether these guideline targets still apply to older patients. More patients now start dialysis with residual kidney function and could benefit from a less frequent dialysis schedule. Older patients have a lower thirst drive, so lower interdialytic gains, reduced appetite, muscle mass and physical activity would potentially allow starting dialysis with less frequent sessions a practical option. Similarly, patients with residual kidney function and lower metabolic activity may not need to meet current dialyser Kt/Vurea clearance targets to remain healthy. Instead, some elderly patients may be at risk of malnutrition and might need liberalisation of the low salt, potassium and phosphate dietary restrictions, or even additional supplements to ensure adequate protein intake. Although a fistula is the preferred vascular access, a forearm fistula may not be an option due to vascular disease, while a brachial fistula can potentially compromise cardiovascular reserve, so a dialysis catheter becomes the de facto access, especially in patients with limited life expectancy. Thus, clinical guideline targets designed for a younger less co-morbid dialysis population may not be equally applicable to the older patient initiating dialysis, and so a more individualised approach to dialysis prescription and vascular access is required.
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Affiliation(s)
- Priyanka Khatri
- Fast and Chronic Programmes, Alexandra Hospital, Queenstown, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, Rowland Hill Street, London, NW3 2PF, UK.
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Hegerty K, Jaure A, Scholes-Robertson N, Howard K, Ju A, Evangelidis N, Wolley M, Baumgart A, Johnson DW, Hawley CM, Reidlinger D, Hickey L, Welch A, Cho Y, Kerr PG, Roberts MA, Shen JI, Craig J, Krishnasamy R, Viecelli AK. Australian Workshops on Patients' Perspectives on Hemodialysis and Incremental Start. Kidney Int Rep 2023; 8:478-488. [PMID: 36938090 PMCID: PMC10014336 DOI: 10.1016/j.ekir.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Most patients with kidney failure commence and continue hemodialysis (HD) thrice weekly. Incremental initiation (defined as HD less than thrice weekly) is increasingly considered to be safe and less burdensome, but little is known about patients' perspectives. We aimed to describe patients' priorities and concerns regarding incremental HD. Methods Patients currently, previously, or soon to be receiving HD in Australia participated in two 90-minute online workshops to discuss views about HD focusing on incremental start and priorities for trial outcomes. Transcripts were analyzed using thematic analysis. Outcomes were ranked on the basis of the sum of participants' priority scores (i.e., single allocation of 3 points for most important, 2 for second, and 1 for third most important outcome). Results All 26 participants (1 caregiver and 25 patients) preferred an incremental HD approach. The top prioritized outcomes were quality of life (QOL) (56 points), residual kidney function (RKF) (27 points), and mortality (16 points). The following 4 themes underpinning outcome priorities, experience, and safety concerns were identified: (i) unpreparedness and pressure to adapt, (ii) disruption to daily living, (iii) threats to safety, and (iv) hope and future planning. Conclusion Patients with kidney failure preferred an incremental start to HD to minimize disruption to daily living and reduce the negative impacts on their education, ability to work, and family life. QOL was the most critically important outcome, followed by RKF and survival.
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Affiliation(s)
- Katharine Hegerty
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Correspondence: Katharine Hegerty, Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland, 4102, Australia.
| | - Allison Jaure
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Nicole Scholes-Robertson
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Kirsten Howard
- Menzies Center for Health Policy and Economics, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Angela Ju
- The University of Sydney, New South Wales, Australia
| | - Nicole Evangelidis
- The University of Sydney, New South Wales, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, New South Wales, Australia
| | - Martin Wolley
- Royal Brisbane and Women’s Hospital, Queensland, Australia
| | | | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Laura Hickey
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Alyssa Welch
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Matthew A. Roberts
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jenny I. Shen
- Division of Nephrology and Hypertension, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jonathan Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rathika Krishnasamy
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
- Department of Nephrology, Sunshine Coast University Hospital, Queensland, Australia
| | - Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
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