"Risks call dialysis into question for nursing home patients"
October 14, 2009
Within a year of starting dialysis, more than half of older nursing home residents die, and nearly another third experience a significant decline in their ability to perform simple tasks, such as feeding themselves, researchers report today.
The fastest-growing group of U.S. patients starting dialysis is those 75 and older, many of whom have health problems other than kidney failure, such as dementia or heart disease. Some observers have questioned whether dialysis, which typically is performed three days a week for three or four hours at a time, is the best option for such patients.
The new study, in The New England Journal of Medicine, focused on all 3,702 U.S. nursing home residents who started dialysis between June 1998 and October 2000 and for whom at least one measurement of ability to do simple daily tasks was available.
The study wasn't designed to show what would have happened to the patients if they didn't go on dialysis, lead author Manjula Kurella Tamura, a Stanford University nephrologist, or kidney doctor, says.
"The results are still important," she says, because most people find it surprising that the patients who received dialysis did so poorly," pointing out the need for doctors to have "open and honest discussions" with elderly patients about the treatment's pros and cons.
Yale University nephrologist Peter Aronson, who wasn't involved in the research, agrees.
For frail elderly nursing home patients, permanent kidney failure "is like metastatic cancer with rapid deterioration and short life expectancy," Aronson says. "The results of this study should inform end-of-life planning for such patients and encourage consideration of alternatives to dialysis, such as palliative care" to relieve symptoms.
Many doctors assume that palliative care is "a death sentence" for patients with permanent kidney failure, internist Robert Arnold, director of palliative care at the University of Pittsburgh, and nephrologist Mark Zeidel, of Harvard University, write in an editorial accompanying the study.
But, they write, small studies of frail elderly patients with permanent kidney failure suggest that death rates and quality of life don't differ much between those who go on dialysis and those who don't. "We must define who among this population will benefit most from dialysis and who will benefit most from conservative therapy."
How hemodialysis is used to treat kidney failure
For more than 35 years, dialysis has been the most common method for treating advanced kidney failure. The vast majority of patients are treated at dialysis centers, where their blood is pumped, a few ounces at a time, through a machine the size of a small refrigerator. A special filter removes harmful wastes, extra salts and fluids. The process helps control blood pressure and maintains a proper balance of chemicals such as potassium and sodium.
Sources: Treatment Methods for Kidney Failure, National Institute of Diabetes and Digestive and Kidney Diseases; U.S. Centers for Disease Control and Prevention
Credit: Adrienne Lewis, USA TODAY