Too Old for Dialysis?

Patient receiving dialysis. ‪中文(繁體)‬: 正在接受血液透析的病患。 (Photo credit: Wikipedia)

Is there any such thing as being too old or too ill for dialysis?

That question is more than a little unfair.

A better question should be do the elderly derive benefit from dialysis?

If someone chooses not to take the option of dialysis what are their options?

How do these options compare in terms of outcome in the elderly population?

A logical argument for the commencement of any patient on dialysis is the premise that dialysis will increase the quantity and quality of life. Dialysis has known complications and can give rise to some morbidity itself. Therefore the benefits of dialysis must exceed the risks of the procedure for it to be the mainstay therapy that it is today. These statements in large part are grounded in scientific research. This research was done in populations that are representative of the population that was dialysed at the time. However the number of patients on dialysis above age 65 is growing rapidly. How does dialysis compare to the alternative in this age group.

What alternative could I possibly be referring to? Transplantation maybe? ....No. By alternative I refer to maximum conservative management or MCM. This is a wonderful phrase that means nondialysis management of renal failure that would usually require dialysis. This type of management scenario is vastly different from that seen in patients on renal replacement therapy. Guidelines such as K/DOQI and others are no longer as strictly applied. The focus is no longer placed on long term outcomes but is instead placed on making the patient as symptom free as possible without dialysis.

Patients may choose maximum conservative management based on religious beliefs or cultural reasons. Some people hate the very idea of dialysis. In my experience elderly patients who have relatives or friends who have been on dialysis are more likely to delay dialysis for as long as possible. Particularly if their dialysis unit is far away from their home and a large percentage of the day will be required just to travel back and forth.

Patients with a high burden of disease conditions are more likely to have a stormy course on dialysis. If there is no likely benefit in terms of quality of life maximum conservative management maybe offered to the patient with an option to dialyse at any time if they change their mind.

A recent paper in the Clinical Journal of the American Society of  Nephrology has recently brought this topic into focus. The conclusion of that study was "Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis." now this is likely to spur much debate in follow up issues of the Journal. But we must remind ourselves that when treating patients your first responsibility is to do no harm. In following this very first rule of medicine we must think about the individual's right to choose based on risk vs benefit for each patient.