STANFORD, Calif. -- Older Americans living in nursing homes experience a significant decline in their ability to perform simple daily tasks -- such as feeding themselves, getting dressed or brushing their teeth -- after starting dialysis, say researchers at the Stanford University School of Medicine.
Starting dialysis to treat kidney failure did not help nursing home patients maintain or improve their functional capacity, said Manjula Kurella Tamura, MD, lead author of a study on the topic, which will appear in the Oct. 15 issue of the New England Journal of Medicine.
"The findings are sobering," said Kurella Tamura, assistant professor of nephrology, who conducted the study with colleagues at Stanford and the University of California-San Francisco. "One of the rationales for starting dialysis in patients with limited life expectancy due to diseases other than kidney failure is that, even if dialysis doesn't extend life, it will improve the quality of life by alleviating symptoms of kidney failure or improving the ability of a patient to care for themselves."
Depending on a patient's other medical problems, this may not be true, the study shows.
Americans over the age of 80 are the fastest-growing segment of the dialysis population, an increase not explained simply by population growth or an increase in diseases that cause kidney failure such as diabetes. This appears to be because physicians are much more willing to provide dialysis therapy to the very elderly, Kurella Tamura said. At least a third of these patients suffer from multiple chronic illnesses, such as heart disease and diabetes, in addition to kidney failure.
Within the United States, 400,000 patients receive dialysis treatment. Dialysis, a method of removing waste products from the blood when the kidneys fail, can be a particularly burdensome therapy for the frail elderly. Patients have to travel to and from the nursing home to dialysis centers for their treatments, typically three times a week for three to four hours per treatment. Many patients have frequent hospitalizations for disease- or treatment-related complications.
Researchers for the study identified 3,702 nursing home patients from national registries who had started dialysis between June 1998 and October 2000 and who had at least one measurement of their functional status available before they started the treatment. Functional status -- considered a key aspect of quality of life and strong predictor of survival -- was measured by assessing the degree of dependence in seven activities of daily living, such as eating, dressing, using the bathroom and changing positions in bed.
Researchers then compared the patients' functional status over the year prior to dialysis to the year following treatment. Results showed that 12 months after starting dialysis, 58 percent of the patients had died, and only 13 percent had maintained the functional level they had before starting dialysis.
"We have tended to overestimate the benefits and ignore or downplay the negative aspects of dialysis when we counsel patients about their treatment options," Kurella Tamura said. "There's a huge burden of adverse symptoms and physical disability even among the patients who receive dialysis, and these aspects are sometimes easy to overlook."
After reviewing the findings, Peter Aronson, MD, a professor of nephrology at Yale University who was not involved in the study, said, "It's a real eye-opener to see how poorly patients do," The study, he added, "will be very useful for clinicians in counseling elderly nursing home patients about their care decisions."
Aronson said he recommends increasing the training for nephrologists on end-of-life care issues. "Many patients have false hopes when they start dialysis. When doctors don't have realistic expectations about how their patients will do, I think it is very hard for patients to make appropriate decisions about their care."
In nursing home patients with multiple chronic illnesses, kidney failure may be a sign of the dying process, and this may explain why functioning continues to decline despite starting dialysis. "In some of these patients, dialysis may be prolonging suffering rather than prolonging life," Kurella Tamura said.
"My hope is that this information will encourage physicians to have open and honest discussions about the treatment choices for kidney failure and the expected outcomes," she added. "There should be an individualized approach that takes into account the patient's goals of care along with prognostic information. Some patients may choose a palliative treatment approach and others may choose dialysis. Regardless of what treatment they choose, this information can help patients prepare for a decrease in their abilities to function and plan for that."
In an accompanying editorial in the journal, two kidney disease experts point to the importance of effective rehabilitation during dialysis for the frail elderly in light of the study results, and the need to better educate elderly patients and their doctors on the benefits and pitfalls of the treatment. Many clinicians assume that declining dialysis treatment is a "death sentence," the editorial's authors write. They said the research by Kurella Tamura reveals the need for larger studies that will be "critical to determining the actual benefit from dialysis in frail elders."
Glenn Chertow, MD, professor of medicine and chief of nephrology, is the other Stanford co-author of the paper. The senior author is Charles McCulloch, PhD, professor of biostatistics at UCSF. Other researchers at UCSF also collaborated on the study.
The research was supported by the National Institute of Aging and grants from the National Center for Research Resources and the National Institute of Diabetes and Digestive and Kidney Diseases.
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