Conservative care may be a reasonable option for elderly kidney failure patients

Worldwide, increasing numbers of older patients are developing kidney failure, or end-stage renal disease (ESRD), that can be treated with renal replacement therapy such as kidney transplantation or dialysis. Some experts have questioned whether older patients, who often have other medical conditions, are likely to benefit from these treatment options and should instead opt to be treated conservatively, with care that includes control of fluid and electrolyte balance, correcting anemia, and providing appropriate palliative and end of life care.

To look at the issue, a team in the country where hemodialysis was originally invented compared survival in older patients with ESRD who chose either dialysis (204 patients) or conservative management (107 patients) between 2004 and 2014. In this single-center observational study, investigators led by Wouter Verberne, MD and Willem Jan Bos, MD,PhD (St. Antonius Hospital, Nieuwegein, in The Netherlands) found no statistically significant survival advantage among patients aged ≥80 years old who chose dialysis over conservative management. In general, patients with additional medical illnesses died sooner than patients without comorbidities.

"We do not conclude that dialysis treatment should not be given to anybody ≥80 years or with severe comorbidity, but we show that the treatment is on average of little advantage regarding survival," said Dr. Verberne. "Our next task is to predict who benefits and who does not. Until we are able to give a better prediction of the results of dialysis treatment at high age, we can merely suggest that conservative management is an option which should honestly be discussed when ESRD is approaching." Dr. Verberne added that more research is needed to determine how different treatment options affect patients' other outcomes, such as quality of life and severity of symptoms.

In an accompanying editorial, Helen Tam-Tham, MSc and Chandra Thomas, MSc, MD (University of Calgary, in Canada) noted that conservative management programs can vary considerably from place to place. "Further research is necessary for enhancing and evaluating the multiple components necessary for a comprehensive conservative management program," they wrote.