Chronic haemodialysis for very old patients
Pedro Leao Neves
There is in the Western World a progressive ageing of the population, and consequently haemodialysis patients are also getting older. Some ethical questions have been raised as a consequence of the economic issues related to the scarcity of available resources. In this paper we review our experience in the treatment of very old chronic haemodialysis patients. Fifty patients (7.2% of our haemodialysis patients) aged over 80 years at the beginning of dialysis were included ( f = 24, m = 26, age = 82.6 [+ or -] 0.3 years). In 42% of the patients the aetiology of renal disease was unknown. In the remainder, the aetiology was: interstitial nephritis 26%, hypertensive nephrosclerosis 14%, chronic glomerulonephritis 8%, diabetes 8% and polycystic disease 2%. There was a great comorbidity: intradialytic hypotension 82%, cardiac disease 74%, gastrointestinal disease 32%, cerebrovascular disease 26%. Vascular access related problems were the main reason for hospitalization. The major cause of death was vascular (cardiac arid cerebral disease). Actuarial survival was 89%, 78%, 56% and 48% at 6, 12, 24 and 36 months, respectively.
We think that haemodialysis is the best available choice for treating very old chronic renal failure patients. However further studies are needed to improve the quality of life of these patients.
Recent data from EDTA and the USA clearly show that the dialysis population is getting older [1-4]. Demographic studies point to a progressive ageing of the population in the Western World , so that in the near future more and more elderly patients will reach chronic renal failure needing replacement therapy. In the medical literature elderly is mostly defined as over 65, and few papers deal with patients with end-stage renal disease (ESRD) aged more than 80 years [6-8].
On the other hand, ethical questions have been raised [2, 9-14] arising from the limitation of available resources [2, 9, 12, 13]. Like others, we think that physiological rather than chronological age should be taken into consideration [8, 15, 16], and that age should never be used as an exclusion criterion in providing medical care. In our country there is no limitation on the provision of dialysis to elderly people. In this study we describe our experience in dialysis treatment of very old patients with end-stage renal disease.
Patients and Methods
In this study we included every patient aged over 80 years admitted between May 1982 and December 1992 to chronic haemodialysis in the five haemodialysis centres in Faro, Evora, Portalegre and Portimao (South of Portugal).
Patients were dialysed for 3-4 hours, 3-4 times a week, with standard cuprophan filters (0.9-1.2[m.sup.2]), first with acetate until the beginning of 1992 and with bicarbonate thereafter. Erythropoietin was introduced in 1990.
The clinical records were reviewed, and we have gathered the following data: age at the beginning of dialysis, sex, aetiology of renal disease, the existence of comorbid conditions, time on dialysis, number of hospitalization days and cause of hospitalization, and cause of death.
Some co-morbid conditions (occurring throughout the treatment period) were considered: (1) intradialytic hypotension (IDH) – blood pressure decrease > 30/20mmHg in 50% or more of the dialysis sessions; (2) hypertension (HT) – blood pressure.> 160/90mmHg or when the patient was under medication; (3) cardiac disease (CD) – coronary disease (clinical and/or electrocardiographic evidence), heart valvular disease with clinical symptoms or congestive cardiac failure; cerebrovascular disease (CBVD): transient ischaemic attacks, vascular thrombosis or cerebral haemorrhage; gastrointestinal disease (GID): gastroduodenal or colorectal disease (haemorrhoids excluded), including mesenteric vascular insufficiency.
Descriptive statistics and the actuarial survival curve were calculated .
Fifty patients over 80 years old were admitted (f = 24, m = 26), corresponding to 7.2% of our dialysis population. The mean age (and standard error) at the beginning of chronic haemodialysis was 82.6 [+ or -] 0.3 years (range 80.1-89.9). The mean time (and standard error) of treatment was 19.6 [+ or -] 2.5 months.
In a number of patients (42%) the aetiology of renal disease was unknown. In the others the aetiology was: interstitial nephritis (26%), hypertensive nephrosclerosis (14%), chronic glomerulonephritis (8%), diabetes (8%) and one patient had adult polycystic renal disease (2%).
Vascular disease was a prevalent comorbid condition in our population (Table I). IDH was also observed in almost all the patients (82%). The main reasons for hospitalization were related to the vascular access and to vascular and gastrointestinal disease (Table II). The total number of hospital admissions was 78, corresponding to 765 hospitalization days (9.8 days per admission and 15.3 days per patient). Vascular disease (cardiac and cerebral) was the main cause of death (Table III). The actuarial survival (Figure), was 89%, 78%, 56% and 48%, at 6, 12, 24 and 36 months, respectively.
Table I. Associated morbidity
No. (%) of
Condition patients affected
Intradialytic hypotension 41 (82)
Cardiovascula disease 37 (74)
Gastrointestinal disease 32 (64)
Cerebrovascular disease 13 (26)
Hypertension 12 (24)
Table II. Hospital admissions
Causes of hospitalization Number
Vascular access 41
Gastrointestinal disease 13
Table III. Causes of death
Cause of death Number
In the Western World the population is progressively getting older, and in consequence more elderly patients will be admitted to chronic renal failure treatment programmes in the coming years . If we consider as elderly people those aged more than 65 years [15, 16], this age group already forms a significant part of the chronic renal population in haemodialysis programmes [1-4]. There have been some studies of those who are more than 75 years old, the ‘very old’ patients , but papers reporting the results in treating these very old patients with end-stage renal disease are few [6-8].
In Portugal there is no health policy limiting the access of old people to advanced care and the decision to initiate dialysis is restricted to the patient and/or his family and the physician. Our 50 patients aged more than 80 years (7.2% of the dialysis population) reflect, at least in part, this ‘open’ health policy. The absence of male predominance in this age group is explained by the greater life expectancy of women. The aetiology of renal disease in our series is in agreement with the literature, except for the significant number of patients where it is unknown [18-20]. The great comorbidity is expected [7, 20, 21]. However, we think that there was a very high prevalence of IDH, which can be attributed to acetate dialysis, cardiovascular disease and autonomic insufficiency . The primary reason for hospitalization was related to vascular access (temporary vascular accesses were commonly used), and this fact can explain the reduced number of hospitalization days [6, 20]. In accordance with some authors [20, 23-25], mortality was mainly related to cardiac and cerebral vascular disease. Withdrawal was the cause of death of only two patients (9% of all deaths), much lower than reported by others [2, 4, 26, 27]. Cultural habits and religion (mostly Roman Catholic) are probably behind this fact. Most families are very reluctant to stop dialysis even when patients are suffering and treatment cannot bring any benefit.
Our patients’ survival is excellent compared with published experience elsewhere [6, 8], doubtless owing in part to patient selection which always exists at the beginning of chronic haemodialysis, but the high prevalence of associated morbidity precludes great selection. We think that ‘in-centre haemodialysis’ is the most appropriate therapy of ESRD in very old patients. There are obvious limitations in grafting the elderly, because of greater selection and insufficient number of organs available, despite the good results in ‘not very old’ patients [28, 29]. There are also problems in treating the very old with CAPD (organic problems and inability to perform the technique) . Chronic regular haemodialysis allows for ‘continuous care’ of somebody who is dependent . Also, bicarbonate dialysis and erythropoietin therapy, two major recent breakthroughs, considerably improved the patients’ health status and well-being on haemodialysis [22, 31-33]. Reports on quality of life of elderly patients in haemodialysis are contradictory [34-37]. Recently, using the Sickness Impact Profile, we found a lower quality of life in our elderly as compared with our younger patients .
At present the very old patients can be successfully treated with haemodialysis and the great concern must be their quality of life. Although the economic issues are important, as doctors we have first and foremost a duty to provide the best available care for our patients.
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