Outcomes of dialysis in the elderly. DNT March 2011 Dr Céline Foote

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1 Outcomes of dialysis in the elderly DNT March 2011 Dr Céline Foote

2 Increasing number of elderly patients on renal replacement therapy Patients per million TOTAL 0-19 yrs yrs yrs yrs yrs >= 85 yrs Acceptance of New Patients Age Specific Rates - Australia ANZDATA report 2009

3 Dialysis?

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5 It is reasonable to consider forgoing dialysis for AKI, CKD or ESRD patients who have a very poor prognosis or for whom dialysis cannot be provided safely. Stage 5 CKD over the age of 75 who meet 2 or more of the following: Clinician s response of No, I would not be surprised if this patient died in the next year High comorbidity score Significantly impaired functional status such as Karnofsky Performance Scale < 40 Severe chronic malnutrition (alb<25g/l)

6 Factors that elderly patients consider in treatment decisions Survival/Longevity Quality of life Burden of treatment Ashby et al. Pall Med 2005 Visser et al. J Nephrology 2009

7 Factors considered by nephrologists Age, comorbid conditions (esp cognitive impairment), quality of life Variability in recommendations for supportive care Nephrologists recommend supportive care in 20% to 60% of elderly pts 1 2 Survey of Australian dialysis units showed 14% planned for supportive care 3 Inconsistencies between primary care, other physicians and nephrologists 4 1 Carson et al. CJASN Murtagh et al. NDT Morton et al. NDT Visser et al. NDT 2007

8 All patients 321 Palliative treatment recommended 63 RRT recommended 258 Pre ESKD 25 Died or palliative treatment 28 Opted for RRT 10 Received RRT 186 Declined RRT and died 6 Pre ESKD 166 Median survival 8.3 mths RRT outcome group 196 Palliative outcome group 34 Median survival 6.3 mths Smith et al. Nephron Clin Pract

9 Characteristics of elderly ESKD patients 586 pts aged 75 yrs commenced dialysis in 2009 in ANZ Unknown number of patients on supportive care pathway Older age 1 2 Increased functional impairment 3 Socially isolated 3 1. Murtagh et al. NDT Carson et al. CJASN Joly et al. JASN 2003

10 Patient Characteristics Number (percentage) Total number 1781 Age (median) 79 (IQR 77 81) Gender (male) 1103 (61.9) Ethnicity (Caucasian) 1622 (91.1) Comorbid conditions No comorbid conditions 151 (8.5) Any cardiovascular disease 1230 (69.1) Coronary heart disease 1063 (59.7) Peripheral vascular disease 579 (32.5) Cerebrovascular disease 422 (23.7) Chronic lung disease 366 (20.6) Diabetes 552 (31.0) Smoking history 947 (53.2) Cancer 392 (22.0)

11 Survival Survival of ANZ elderly dialysis patients Follow up (years) Elderly cohort 75 years 80 years

12 Predictors of survival Factors identified with poorer survival on dialysis include: Older age Comorbid conditions Malnutrition Functional status Late referral to a nephrologist Unplanned start Several studies have identified comorbidity score as a strong predictor of mortality

13 Lamping et al demonstrated decreased survival with increasing number of comorbid conditions in pts aged 70 The Lancet 2000

14 Comorbid score* is associated with survival in elderly ANZ dialysis patients Survival or more Followup (years) Comorbid HR 95%CI P value score < < <0.001 * Includes coronary heart disease, peripheral vascular disease, cerebrovascular disease, chronic lung disease and diabetes

15 There may be no survival advantage with increasing comorbidity Murtagh et al. NDT 2007

16 Chandna et al. NDT 2010

17 Baseline characteristics predict survival on dialysis Risk Category Risk Score 6 mth survival Low 0 92% Median 2 83% High 9 30% Variable BMI < DM 1 CHF stage III to IV 2 PVD stage III to IV 2 Dysrhythmia 1 Active malignancy 1 Severe behavioural 2 disorder Dependency for transfers 3 Unplanned dialysis 2 N points Couchoud et al. NDT 2009

18 Patient and practice variables discriminate survival in elderly ANZ dialysis patients Independent factors in model: age, low BMI, comorbid score, late referral, unprepared access, peritoneal dialysis at 3 months

19 Survival with supportive care Joly (37) Murtagh (77) Carson (29) Study (n pts) Smith* (63) Wong* (73) Ellam* (69) Chandna* (155) * Patients of all ages included median survival (months) Joly et al. JASN 2003, Murtagh et al. NDT 2007, Carson et al. CJASN 2009, Smith et al. Nephron Clin Pract 2003, Wong et al. Ren Fail 2007, Ellam et al. Q JMed 2009, Chandna et al. NDT 2010

20 Survival with supportive care also associated with co morbidity Wong et al. Renal Failure 2007

21 Quality of life of elderly dialysis population QoL of all dialysis patients is decreased compared to general population No difference in mental component of elderly patients 1 QoL of elderly dialysis is relatively better than younger pts in cross sectional study 2 QoL is better preserved over time on dialysis compared to younger patients 3 1 Lamping et al. Lancet Rebollo et al. NDT Unruh et al JAGS 2008

22 Rebollo et al. NDT 2001

23 Quality of life with supportive care SF 36 scores compared to age/sex matched general population SF36 domain Dialysis group (n=134) PF Palliative care group (n=45) RP BP GH VT SF RE MH Yong et al. Pall Med 2009

24 Dialysis is associated with increased hospitalisation Rates of hospitalisation in elderly RRT patients days per year 1 2 Rates of hospitalisation in elderly supportive care patients days per year 1,3 1 Carson et al. CJASN Rohrich et al. NDT Wong et al. Renal Failure 2007

25 4.3% days survived 47.5% days survived Carson et al. CJASN 2009

26 Dialysis is associated with functional decline in elderly patients More than 30% of patients aged 80 had functional loss 6 months after dialysis initiation 1 Majority of elderly nursing home residents have died or lost function 12 months after dialysis initiation 2 1. Jassal et al. NEJM 2009, 2. Tamura et al. NEJM 2009

27 Carers of elderly dialysis patients have impaired quality of life Median 56 to 70 hours of care per week 1 All SF36 components affected 32% of carers had signs of depression 1 Increasing carer burden 1 with: Peritoneal dialysis Poor functional status Decreased QOL of elderly pts No information on carers of supportive care patients 1. Belasco et al. AJKD 2006

28 Shared decision making Informed decision Survival Quality of life /Treatment burden

29 Dialysis?

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