The population of people on dialysis is graying; adults aged 75 and older are the fastest growing group beginning this treatment. But often doctors don't answer their key question: "How long can I expect to live?"
Researchers at Tufts University and the University of New Mexico underscored the disconnect in a recent review. Ninety-five percent of patients said they and their families want to be given information about life expectancy, the authors noted. But a 2010 survey cited in the study found that 90 percent of patients had never discussed the issue with their nephrologists.
The researchers called for doctors to explain prognosis to patients and undertake shared decision-making, assessing the benefits and burdens of treatment in light of a person's values. That recommendation has also been adopted by the Renal Physicians Association and the American Society of Nephrology. But the advice is widely ignored in practice.
I interviewed several experts and reviewed almost two dozen scientific reports for some answers about the prognosis for older adults on dialysis.
What is known about life expectancy among older dialysis patients?
Older people on dialysis have a significantly shortened life expectancy, compared with peers in their age group. This is especially true when they have multiple illnesses: up to one-third of older adults with severe kidney disease have four or more other ailments, such as diabetes, hypertension, heart disease or dementia.
Dr. Jeffrey Berns, who heads the nephrology fellowship program at the Hospital of the University of Pennsylvania, pointed me to some useful data from the United States Renal Data System.
The data show that 70- to 74-year-olds on dialysis can expect to live 3.6 years on average, compared with 12.2 years for all Americans of that age. For 75- to 79-year-olds, the figures dropped to 3.1 years versus 9.2 years. For 80- to 75-year-olds, they were 2.5 years versus 6.7 years. And for those 85 years and older, average life expectancy was two years versus 3.5 years. (The dialysis data is for 2011, and the general population data is from 2009.)
"Some people will do better, and others will do worse," Dr. Berns said. "It's hard to predict with any degree of precision, but obviously the more conditions someone has, the less likely it is their life expectancy will be enhanced by starting them on dialysis."
This is especially true of patients with ischemic heart disease, characterized by reduced blood flow to the heart. "That condition alone is sufficient to negate any potential benefit from dialysis in the elderly," Dr. Berns said.
Do other factors affect life expectancy?
Research suggests that older adults who are frail and unable to dress, toilet, bathe, eat on their own or get out of bed in the morning also tend not to live long on dialysis.
"If someone can't perform multiple activities of daily living, you need to be introspective about whether dialysis adds to their longevity," said Dr. Leslie Spry, medical director of The Dialysis Center of Lincoln, in Nebraska, and a spokesman for the National Kidney Foundation. "If they're otherwise relatively healthy and getting around all right, that's another matter altogether."
One simple question that draws on the doctor's clinical judgment — "Would you be surprised if Mr. Smith died within the next six months?" — turns out to be highly predictive of who will survive.
New research from the Mayo Clinic, presented last month at the annual meeting of the American Society of Nephrology, suggests other considerations. The study looked at 379 patients aged 75 and older at the Rochester, Minn., medical center between 2007 and 2011. Slightly more than three-quarters of them began dialysis in the hospital after an acute exacerbation of chronic kidney disease, a severe infection, or an acute kidney injury following surgery.
Those who started dialysis in the intensive care unit (60 percent of the hospital population) did especially poorly. Only 27 percent survived the next six months; 23 percent were alive at one year. Patients who started dialysis in the hospital but outside the I.C.U. had better results initially, but those worsened over time: 12 percent died in the first six months, but only 59 percent were alive after a year.
The Mayo Clinic draws especially ill patients from across the country and the results may not be generalizable. But they suggest that many sick older patients who begin dialysis while in the hospital may not survive for long, according to lead researcher Dr. Bjorg Thorsteindottir, a health care delivery scholar at the Mayo Clinic.
Still, "a healthy elderly patient should absolutely consider dialysis and can do very well," she said.
Will I live longer on dialysis than on supportive therapy?
Most studies suggest that older adults on dialysis will live longer than those who decide against this treatment and choose instead to treat symptoms such as pain or nausea — so-called supportive therapy. According to a review of studies of patients on supportive therapy, life expectancy was at least six months, with a range of up to 24 months. On average, that is shorter than the life expectancy for older adults on dialysis.
But in general, the evidence supporting a survival advantage in very old patients on dialysis is weak, according to Dr. Thorsteindottir. And there's growing concern among experts that too many elderly patients with severe kidney disease may be starting dialysis without the potential for significant benefit.
"Concerns about overtreatment are focused on older adults, especially those who are frail or have other severe or life-limiting conditions," according to the authors of an editorial in The Journal of the American Medical Association last year.
The bottom line: older patients and their families deserve to understand what they can expect when a physician recommends dialysis. This is a demanding treatment and one whose potential benefits and burdens deserve careful consideration.
This post has been revised to reflect the following correction:
Correction: December 6, 2013
An earlier version of this post misstated the results of a study of patients aged 75 and older in Rochester, Minn. The study found that of the patients who started dialysis in the intensive care unit, 23 percent were alive at one year. It is not the case that 23 percent died within a year.
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