Simple measures of the severity of an older kidney failure patient's illness when starting dialysis -- such as whether dialysis was initiated in an inpatient setting, the length of the patient's hospital stay, and the use of other life-sustaining procedures -- can convey meaningful information about the patient's prognosis, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). The information can help guide physicians as they determine the best care for patients on dialysis.
Little is known about the circumstances under which older adults with kidney failure initiate dialysis or about how these circumstances might affect patients' outcomes. To investigate, Susan Wong, MD (University of Washington, Seattle) and her colleagues analyzed national registry data pertaining to 416,657 Medicare beneficiaries aged 67 years and older who initiated chronic dialysis between January 1995 and December 2008. The researchers looked at the relationship between health care intensity around the time of dialysis initiation and subsequent aspects of patients' health.
"Our research sought to provide important information on patients' anticipated illness trajectory that could assist providers and patients in formulating treatment decisions and setting realistic expectations for the future," said Dr. Wong.
Among the major findings: • Most patients (64.5%) initiated dialysis in the hospital, including 36.6% who were hospitalized for two or more weeks and 7.4% who underwent one or more intensive procedures, including mechanical ventilation, feeding tube placement, and CPR. Also, the proportion of patients initiating chronic dialysis in the inpatient setting has been rising in recent years. • Compared with patients who initiated dialysis in the outpatient setting, those who received the highest intensity of care at dialysis initiation (those who were hospitalized for two or more weeks and received at least one intensive procedure) had shorter survival times (median 0.7 vs 2.1 years), spent a greater percentage of remaining followup time in the hospital (median 22.9% vs 3.1%), were more likely to undergo subsequent intensive procedures (44.9% vs 26.0%), and were less likely to have discontinued dialysis before death (19.1% vs 26.2%).
The findings indicate that most older adults initiate chronic dialysis in the hospital, and those who have a prolonged hospital stay and receive other forms of life support around the time of dialysis initiation have limited survival and more intensive use of subsequent healthcare.
"Many older patients are unaware of their illness trajectory after starting chronic dialysis, and many nephrologist are not comfortable with discussing prognosis, although patients express wanting this information. We hope that our findings can be used to supplement providers' knowledge and increase their confidence and willingness to discuss prognosis with their patients," said Dr. Wong.
In an accompanying editorial, Amy Williams, MD (Mayo Clinic) stated that the study is "the first to provide insight into the association of site, intensity of care, and length of hospitalization at the initiation of dialysis to the subsequent burden of disease. With these data, translated in the context of patient preferences, we can better design individualized care that will allow patients to meet goals and smooth transitions during health status changes, leading to fewer ICU admissions and ICU deaths, better symptom management, improved quality of life, and decreased cost of end-of-life care."
- A. W. Williams. Older Adults with CKD and Acute Kidney Failure: Do We Know Enough for Critical Shared Decision Making? Journal of the American Society of Nephrology, 2013; DOI: 10.1681/ASN.2013090981
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