For Some Older Adults With Kidney Failure, Dialysis May Not be the Best Option

Whether dialysis is the best option for kidney failure, and if so, when to start, should be considered more carefully, according to a new study. If older adults who weren’t healthy enough for a kidney transplant started dialysis as soon as their kidney function fell below a certain threshold – instead of waiting – they had about a week more to live, the Stanford Medicine researchers and their colleagues found. Perhaps more critically, in addition to the time they spent on dialysis, they spent an average of two more weeks in hospitals or nursing facilities. Montez Rath is the lead author of a study on dialysis, life expectancy and time at home published in Annals of Internal Medicine. Manjula Tamura, MD, a professor of nephrology, is the lead author.

Dialysis Often Has Side Effects

Patients with kidney failure who are healthy enough for a transplant can receive a donated kidney to clear their blood of toxins and excess fluid. However, this option is not available to many older adults with additional conditions such as heart or lung disease or cancer. For these patients, doctors often recommend dialysis – a treatment that cleanses the blood like a healthy kidney – when patients progress to kidney failure. Kidney failure occurs when the estimated glomerular filtration rate (eGFR), a measure of kidney function, falls below 15.

Patients and their family members sometimes assume that dialysis is their only option or that it will significantly prolong life, says Montez Rath. “They often say yes to dialysis without really understanding what it means.” However, patients can take medication instead of dialysis to treat the symptoms of kidney failure such as water retention, itching and nausea. Tamura added that dialysis comes with side effects such as cramps and fatigue, and usually requires a three- to four-hour visit to a clinic three times a week. This is a fairly intensive therapy that involves a major lifestyle change.

Life Expectancy and Time at Home

The researchers conducted the study to determine what dialysis means for older adults who are not eligible for a transplant: whether and how much it prolongs life and how many days they spend in an inpatient facility such as a hospital, nursing home or rehabilitation center. The team analyzed the medical records of 20,440 patients (98% of them men) from the US Department of Veterans Affairs from 2010 to 2018. The patients were 65 years and older, had chronic kidney failure, were not being evaluated for a transplant, and had an eGFR below 12. By simulating a randomized clinical trial with electronic health records, they divided the patients into groups: those who started dialysis immediately and those who waited at least a month. Over a three-year period, about half of the patients in the group that waited never started dialysis.

Patients who started dialysis immediately lived an average of nine days longer than those who waited, but they spent 13 days longer in an inpatient facility. Age also played a role: patients between 65 and 79 years of age who started dialysis immediately lived an average of 17 days less and spent 14 days longer in an inpatient facility; patients over 80 years of age who started dialysis immediately lived an average of 60 days longer but spent 13 days more in an inpatient facility. Patients who never underwent dialysis died on average 77 days earlier than those who started dialysis immediately, but spent 14 more days at home.

According to the researchers, the study shows that you may survive longer if you start dialysis right away, but you spend a lot of time on dialysis and are more likely to require hospitalization. Tamura noted that doctors sometimes recommend dialysis because they want to give patients hope or because the disadvantages of the treatment are not always clear. However, the study suggests that physicians and patients may want to wait until eGFR drops further and consider symptoms as well as personal preferences before starting dialysis.

“Different patients have different goals,” she said. According to Tamura, for some it is a blessing to have this option of dialysis, for others it can be a burden. She added that it might be helpful if physicians would present dialysis for frail, older adults as a palliative treatment designed primarily to relieve symptoms. Currently, dialysis is often presented to patients as a choice between life and death,” she said. ”When it is presented this way, patients have no room to consider whether the treatment meets their goals, and they tend to overestimate the benefits and well-being they might experience. However, when treatment is presented as symptom relief, patients can more easily understand that there are trade-offs.”