Correspondence
Functional Status of Elderly Adults Receiving Dialysis
N Engl J Med 2010; 362:468-469February 4, 2010
- Article
To the Editor:
Frail elderly patients with end-stage renal disease (ESRD) entering dialysis programs have a substantial and sustained decline in functional status, according to the article by Kurella Tamura et al.1 and the letter by Jassal et al.2 (Oct. 15 issue). In the accompanying editorial, Arnold and Zeidel3 point to a lack of randomized trials to evaluate the benefit of dialysis in this group. The key difficulty in interpreting comparative survival data is uncertainty surrounding when dialysis would have started in conservatively treated patients. We used regression analysis of measurements of the estimated glomerular filtration rate to calculate an equivalent putative dialysis start date for a group of patients with ESRD who were over 70 years of age and who were treated conservatively and compared their survival with a similar group that underwent dialysis.4 Both groups had similar scores on the Charlson Comorbidity Index, even though the conservatively treated group was older (mean age, 81.6 years vs. 76.4 years). Patients who opted for dialysis had improved survival (median, 37.8 months vs. 13.9 months), but almost every additional day of increased survival was at the expense of a hospital visit or intervention. Patients who were undergoing dialysis were more likely to die in an acute hospital setting (odds ratio, 4.15).
Aine Burns, M.D.
Andrew Davenport, M.D.
Royal Free National Health Service Trust, London, United Kingdom
aine.burns@royalfree. nhs. uk No potential conflict of interest relevant to this letter was reported.
4 References1
Kurella Tamura M ,Covinsky K ,Chertow G ,Yaffe K ,Landefeld C ,McCulloch C . Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009;361:1539-1547
Full Text | Web of Science | Medline2
Jassal SV ,Chiu E ,Hladunewich M . Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med 2009;361:1612-1613
Full Text | Web of Science | Medline3
Arnold RM ,Zeidel ML . Dialysis in frail elders -- a role for palliative care. N Engl J Med 2009;361:1597-1598
Full Text | Web of Science | Medline4
Carson R ,Juszczak M ,Davenport A ,Burns A . Is conservative management an equivalent option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009;4:1611-1619
CrossRef | Web of Science | Medline
To the Editor:
Kurella Tamura et al. ask, “Why does functional status decline in so many nursing home residents despite the treatment of uremia?” The investigators' answers to this question missed a most relevant point: in a nursing home, brain alterations dominate the clinical picture and explain much of the functional decline. Not only are hemodialysis sessions started in parallel with cognitive fluctuation caused by the uremic state, but further cognitive instability derives from huge, uncontrollable hemodynamic and metabolic changes in the brain during hemodialysis sessions. Hypotension, hypertension, hypoxemia, electrolyte disorders, dialysis disequilibrium, accumulation of drugs (and of anticholinergic effects), vitamin deficiencies, and depression contribute to cognitive fluctuations. In the elderly, these phenomena assume extraordinary significance, and hemodialysis sessions constantly generate delirium and other acute cognitive disorders1 that may coalesce in subsequent sessions. Williams et al.2 detected gradual cognitive worsening, in intervals of 1, 24, and 67 hours after hemodialysis. Research should focus on better physiological control of hemodialysis sessions, which would possibly prevent cognitive fluctuations and improve the functional status of elderly patients living in nursing homes.
Almir R. Tavares, Jr., M.D., Ph.D.
Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
almirtav.bh@gmail. com Cláudia P. Caciquinho Vieira, M.D.
Materdei Hospital, Belo Horizonte, BrazilPedro A. Macedo Souza, M.D.
Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, BrazilNo potential conflict of interest relevant to this letter was reported.
2 References1
Murray AM ,Tupper DE ,Knopman DS , et al. Cognitive impairment in hemodialysis patients is common. Neurology 2006;67:216-223
CrossRef | Web of Science | Medline2
Williams MA ,Sklar AH ,Burright RG ,Donovick PJ . Temporal effects of dialysis on cognitive functioning in patients with ESRD. Am J Kidney Dis 2004;43:705-711
CrossRef | Web of Science | Medline
Author/Editor Response
We applaud the efforts of Burns and Davenport to compare aspects of quality of life in addition to length of life in elderly patients receiving dialysis, as compared with conservative treatment, since such considerations are likely to be important for decision making.
We agree with Tavares and colleagues that cognitive impairment is an important contributor to functional decline in elderly nursing home residents with ESRD. In the Supplementary Appendix that accompanied our article (available at NEJM.org), we indicated that a diagnosis of dementia was associated with a relative reduction of 40% in the odds of maintaining functional status 1 year after starting dialysis. We did not evaluate the association between delirium (dialysis-associated or otherwise) and functional decline, although we agree that such an evaluation might be informative. Ongoing clinical trials, such as those being conducted by the Frequent Hemodialysis Network (ClinicalTrials.gov numbers, NCT00264758 and NCT00271999), for which I am a coinvestigator, may provide insight into whether cognitive function can be improved with modifications to the standard thrice-weekly hemodialysis schedule and whether such a result is accompanied by improvements in functional status.1
Manjula Kurella Tamura, M.D., M.P.H.
Stanford University School of Medicine, Palo Alto, CA
mktamura@stanford.edu Since publication of her article, the author reports no further potential conflict of interest.
1 References1
Suri RS ,Garg AX ,Chertow GM , et al. Frequent Hemodialysis Network (FHN) randomized trials: study design. Kidney Int 2007;71:349-359
CrossRef | Web of Science | Medline
Author/Editor Response
We concur with the comments of Burns and Davenport and echo their suggestion that conservative care be considered for elderly nursing home residents with ESRD. However, we would strongly caution against a policy of denying aged patients dialysis care on the basis that they may have poor functional outcomes. Our data have shown that dependency occurred after the initiation of dialysis in previously healthy persons, suggesting that the process of dialysis initiation may be at issue. It is important to recognize that dialysis initiation has an overwhelming psychological effect, which, when coupled with the physical demands of treatment, leads to feelings of hopelessness and a loss of self-efficacy and subsequent functional decline. In our experience, such decline can be reversible, and we advocate that all frail, vulnerable older patients be offered rehabilitative care around the time of dialysis initiation.1,2 Rather than doing less dialysis, the nephrology community should be advocating for treatment programs that offer more than just dialysis.1,3
Sarbjit Vanita Jassal, M.D.
University Health Network, Toronto, ON, Canada
vanita.jassal@uhn. on. ca Michelle Hladunewich, M.D.
Sunnybrook Health Sciences Centre, Toronto, ON, CanadaSince publication of their letter, the authors report no further potential conflict of interest.
3 References1
Jassal SV ,Watson D . Dialysis in late life: benefit or burden. Clin J Am Soc Nephrol 2009;4:2008-2012
CrossRef | Web of Science | Medline2
Li M ,Porter E ,Lam R ,Jassal SV . Quality improvement through the introduction of interdisciplinary geriatric hemodialysis rehabilitation care. Am J Kidney Dis 2007;50:90-97
CrossRef | Web of Science | Medline3
Jassal SV, Watson D. Doc, don't procrastinate . . . rehabilitate, palliate, and advocate. Am J Kidney Dis (in press).
- Citing Articles (2)
Citing Articles
1
Jeroen P. Kooman, Tom Cornelis, Frank M. van der Sande, Karel M.L. Leunissen. (2012) Renal Replacement Therapy in Geriatric End-Stage Renal Disease Patients: A Clinical Approach. Blood Purification 33:1-3, 171-176
CrossRef2
Aine BURNS, Andrew DAVENPORT. (2010) Maximum conservative management for patients with chronic kidney disease stage 5. Hemodialysis International 14, S32-S37
CrossRef
