Older Dialysis Patients May Not Derive Benefit from Dialysis

[caption id="attachment_636" align="alignright" width="300" caption="Dialysis in the Elderly "][/caption]

Recently I asked the question can you be too old for dialysis. Then today I noticed a news release based on an article published in the new England Journal of Medicine which suggests that elderly patients living in nursing homes may not be deriving significant benefit from dialysis. I had feedback on my own article, which suggested the very concept of limiting dialysis based on age is repulsive. Let me make it quite clear, that it was never my intention to suggest such a thing.

My point remains that in order for a treatment to be offered, it must be shown to be of benefit to the patient. The first rule of medicine is ...at least do no harm. In the case of dialysis the elderly population is not as frequently studied survival numbers as well as quality of life data is limited. Dialysis is quite an undertaking at any age. However in elderly patients the situation is complicated by issues with immobility and transport to and from the dialysis centre.

If it is indeed true that after the initiation of dialysis in nursing home residents the functional decline that occurs is unchecked by dialysis then we must ask ourselves why are we dialysing this group of patients. Who stands to benefit from their dialysis if it is not them directly then who?

Functional status decline after commencing dialysis is based on the presence of multiple conditions which precede the initiation of dialysis, these conditions are not correctable in the majority of cases and in themselves represent a form of end stage disease of organs other than the kidney. Not only may dialysis not benefit patients which such a high burden of disease but I would go further to say that the fluid shifts which occur in standard hemodialysis may theoretically cause further harm depending on the co-morbidities present.

The point is not to deny any patient group dialysis based on any non modifiable variable such as age but to better be able to advise patients and their families about realistic outcomes when initiating dialysis in all patient groups. Right now the data in the elderly population is sparse and we are just now beginning to see some indication of what the true position maybe.  I for one am looking forward to reading the correspondence that this paper in the New England Journal of medicine is sure to bring.