Currently, dialysis is often framed to patients as a choice between life and death. When it’s presented in this way, patients don’t have room to consider whether the treatment aligns with their goals, and they tend to overestimate the benefits and well-being they might experience
Manjula Tamura
The researchers conducted the study to quantify what dialysis entails for older adults who are ineligible for a transplant: whether and how much it prolongs life, along with the relative number of days spent in an inpatient facility such as a hospital, nursing home or rehabilitation center. The team evaluated the health records, from 2010 to 2018, of 20,440 patients (98% of them men) from the U.S. Department of Veterans Affairs. The patients were 65 and older, had chronic kidney failure, were not undergoing evaluation for transplant and had an eGFR below 12.
Simulating a randomized clinical trial with electronic health records, they divided patients into groups: those who started dialysis immediately, and those who waited at least a month. Over three years, about half of the patients in the group who waited never started dialysis.
Patients who started dialysis immediately lived on average nine days longer than those who waited, but they spent 13 more in an inpatient facility. Age made a difference: Patients 65 to 79 who started dialysis immediately on average lived 17 fewer days while spending 14 more days in an inpatient facility; patients 80 and older who started dialysis immediately on average lived 60 more days but spent 13 more days in an inpatient facility. Patients who never underwent dialysis on average died 77 days earlier than those who started dialysis immediately, but they spent 14 more days at home.
“The study shows us that if you start dialysis right away, you might survive longer, but you’re going to be spending a lot of time on dialysis, and you’re more likely to need hospitalization,” Montez Rath said.
Tamura noted that physicians sometimes recommend dialysis because they want to offer patients hope or because the downsides of the treatment haven’t always been clear. But the study indicates physicians and patients may want to wait until the eGFR drops further, Tamura said, and should consider symptoms along with personal preferences before starting dialysis. “Different patients will have different goals,” she said. “For some it’s a blessing to have this option of dialysis, and for others it might be a burden.”
It may be helpful, she added, if clinicians portray dialysis for frail, older adults as a palliative treatment — primarily intended to alleviate symptoms. “Currently, dialysis is often framed to patients as a choice between life and death,” she said. “When it’s presented in this way, patients don’t have room to consider whether the treatment aligns with their goals, and they tend to overestimate the benefits and well-being they might experience. But when treatment is framed as symptom-alleviating, patients can more readily understand that there are trade-offs.”
Source: Stanford Medicine
Rohit Malhotra is a medical expert and health journalist who offers evidence-based advice on fitness, nutrition, and mental well-being. His articles aim to help readers lead healthier lives.
