Chronic haemodialysis for very old patients

Chronic haemodialysis for very old patients

Pedro Leao Neves

Summary

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.

Introduction

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 [5], 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 [17].

Results

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

Vascular 10

Infection 9

Other 5

Table III. Causes of death

Cause of death Number

Cerebrovascular 5

Cardiovascular 4

Infection 3

Neoplasia 3

Withdrawal 2

Cachexia 2

Other 3

Discussion

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 [5]. 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 [15], 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 [22]. 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) [30]. Chronic regular haemodialysis allows for ‘continuous care’ of somebody who is dependent [5]. 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 [38].

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.

References 1. Brunner FP, Broyer M, Brynger H, et al. Survival on renal replacement therapy: data from the EDTA Registry. Nephrol Dialysis Transplant 1988;2:109-22. 2. Eggers PW. Health care policies/economics of the geriatric renal population. Am F Kidney Dis 1990;16: 384-91. 3. Brunner FP, Selwood NH. Profile of patients on RRT in Europe and death rates due to major causes of death groups. Kidney Int 1992;42(suppl 38):S4-15. 4. Kjellstrand CM, Hylander B, Collins AC. Mortality on dialysis – on the influence of early start, patient characteristics, and transplantation and acceptance rates. Am F Kidney Dis 1990;15:483-90. 5. Kaiser FE. Principles of geriatric care. Am F Kidney Dis 1990;16:354-9. 6. Chester AC, Rakowski TA, Argy Jr WP, et al. Hemodialysis in the Eighth and Ninth decades of life. Arch Intern Med 1979;139:1001-5. 7. Neves PL, Bexiga I, Pinto I, Amorim JP. Hemodialise Cronica com Acetato em Doentes com Idade Superior a 70 Anos. Acta Med Port 1992;5:11-13. 8. Morderchowicz GA, Winkler J, Wittenberg C, et al. Renal replacement therapy in the ninth decade of life. Geriatr Nephrol Urol 1992;2:147-9. 9. Brodeur D. Ethical principles in geriatric nephrology. Am F Kidney Dis 1990;16:372-4. 10. Rennie D, Rettig RA, Wing AJ. Limited resources and the treatment of end stage renal failure in Britain and the United States. Q F Med 1985;219:321-36. 11. Cummings NB, Ethical issues in geriatric nephrology: overview. Am F Kidney Dis 1990;16:367-71. 12. Rothenberg LS. Ethical concerns for the elderly with ESRD. Adv Peritoneal Dialysis 1990(suppl);6:6-10. 13. Rothenberg LS. Withholding and withdrawing dialysis from elderly ESRD patients: Part 1. A historical view of the clinical experience. Geriatr Nephrol Urol 1992;2:109-17. 14. Rothenberg LS. Withholding and withdrawing dialysis from elderly ESRD patients: Part 2. Ethical and policy issues. Geriatr Nephrol Urol 1993;3:23-41. 15. Oreoupolos DG. The aging kidney. Adv Peritoneal Dialysis 1990(suppl);6:2-5. 16. Woodhouse KW, Wynne H, Baille S, et al. Who are the frail elderly? Q F Med 1988;255:505-6. 17. Kaplan EL, Meier P. Non parametric estimation from incomplete observations. F Am Stat Soc C 1958;53:457-81. 18. Gokal R, Jakubowski C, King J, et al. Outcome in patients on continuous ambulatory peritoneal dialysis and haemodialysis: 4-year analysis of a prospective multicentre study. Lancet 1987;ii:1105-8. 19. Burton PR, Walls J. Selection-adjusted comparison of life-expectancy of patients on continuous ambulatory peritoneal dialysis, haemodialysis, and renal transplantation. Lancet 1987;i:1115-18. 20. Williams AJ, Nicholl JP, El Nahas AM, et al. Continuous ambulatory peritoneal dialysis and haemodialysis in the elderly. Q F Med 1990;274:215-23. 21. Capuano A, Sepe V, Cianfrone P, et al. Cardiovascular impairment, dialysis strategy and tolerance in elderly and young patients on maintenance hemodialysis. Nephrol Dialysis Transplant 1990;5:1023-30. 22. Henrich WL. Hemodynamic instability during hemodialysis. Kidney Int 1986;30:605-12. 23. Williams AJ, Antao AJO. Referral of elderly patients with end-stage renal failure for renal replacement therapy. Q F Med 1989;268:749-56. 24. Benevent D, Benzakour M, Peyronnet P, et al. Comparison of continuous ambulatory peritoneal dialysis and hemodialysis in the elderly. Adv Peritoneal Dialysis 1990(suppl);6:68-71. 25. Walls J. Dialysis in the elderly: some UK experience. Adv Peritoneal Dialysis 1990(suppl);6:82-5. 26. Hirsh DJ. Death from dialysis termination. Nephrol Dialysis Transplant 1989;4:41-4. 27. Neu S, Kjellstrand CM. Stopping long-term dialysis. N Engl F Med 1986;314:14-20. 28. Schulak JA, Hricik DE. Kidney transplantation in the elderly. Geriatr Nephrol Urol 1991;1:105-12. 29. Morris GE, Jamieson NV, Small J, et al. Cadaveric renal transplantation in elderly recipients: is it worthwhile? Nephrol Dialysis Transplant 1991;6:887-92. 30. Nissenson AR. Chronic peritoneal dialysis in the elderly. Geriatr Nephrol Urol 1991;1:3-12. 31. Graeffe I, Milutinovich J, Folette WC, et al. Less dialysis-induced morbidity and vascular instability with bicarbonate dialysate. Ann Int Med 1978;88:332-6. 32. Mayer G, Thum J, Cada EM, et al. Working capacity is increased following recombinant human erythropoietin treatment. Kidney Int 1988;34:525-8. 33. Delano BG. Improvements in quality of life following treatment with r-HuEPO in anemic hemodialysis patients. Am F Kidney Dis 1989;14:14-18. 34. Avram MR, Pena C, Burrell D, et al. Hemodialysis and the elderly patient: potential advantages as to quality of life, urea generation, serum creatinine, and less interdialytic weight gain. Am F Kidney Dis 1990;16:342-5. 35. Gutman RA, Stead WW, Robinson RR. Physical activity and employment status of patients on maintenance dialysis. N Engl F Med 1981;304:309-13. 36. Julius M, Hawthorne VM, Carpenter-Alting P, et al. Independence in activities of daily living for end-stage renal disease patients: biomedical and demographic correlates. Am F Kidney Dis 1989;13:61-9. 37. Harris LE, Luft FC, Rudy DW, Tierney WM. Clinical correlates of functional status in patients with chronic renal insufficiency. Am F Kidney Dis 1993;21:161-6. 38. Neves PL, Nunes I, Jardim J, et al. Estado funcional de uma Populacao em Hemodialise Cronica (HDC): Correlacoes Clinicas e Laboratoriais [Abstract]. 8 [degrees] Congresso Portugues de Nefrologia, 1993.

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