http://www.ncbi.nlm.nih.gov/pubmed/22570459

JAMA. 2012 May 9;307(18):1919-20.

The sad truth about early initiation of dialysis in elderly patients.

Rosansky SJ.

Source

Dorn Research Institute, William Jennings Bryan Dorn VA Medical Center, 526 N Trenholm Rd, Columbia, SC 29206, USA. sjrcra@yahoo.com

"Even if eGFR overestimates renal function in some elderly patients, the lack of evidence of a survival benefit for dialysis initiation at an eGFR higher than 10 mL/min per 1.73 m2 means that only 36% of the patients who started dialysis in 2008 were justifiable. Even at very low levels of eGFR, the choice of dialysis should be balanced against the option of an “intensive program of multidisciplinary care and support,” especially for those patients with high comorbidity and limited life expectancy.8 One way to manage the increasing predialysis elderly population is to provide funding for hospital and home-based multidisciplinary programs that monitor and treat patients with eGFRs lower than 15 mL/min per 1.73 m2. Clinical information from these programs, including the rate of decline of renal function, reason for dialysis initiation, and comorbidities vs outcomes, can be collected by a registry such as the US Renal Data System to provide objective data for future dialysis decisions. Patients and their family members must be reassured that if a palliative care approach is chosen, there will not be a reduction in care and symptom relief will be provided along with a focus on preserving quality of life.8 The decision to initiate dialysis should be a joint decision made by patients and their nephrologists, after full disclosure of the potential harms and benefits of dialysis vs nondialysis management. The public perception that pursuit of dialysis is always in patients' best interest should be replaced by a more realistic view of the “sad truth” about early dialysis initiation in elderly patients.5"