Mortality in the Elderly on Dialysis

Iyasere, Osasuyi; Brown, Edwina A.

doi:10.2215/cjn.03650415

Cited by 18 publications

(12 citation statements)

References 19 publications

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“…Thus, a “Fistula or Graft First” approach appears more rational considering the multidimensional needs of older patients on HD. In this context, we and others reason that maintaining physical ability and self-sufficiency in older patients with ESKD is the most important factor in choice of vascular access [ 52 , 53 ]. This pilot study will yield valuable data related to participant recruitment, study dropout and the conduct of study assessments to inform operational requirements for a large scale trial.…”

Section: Discussionmentioning

confidence: 99%

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

Murea

Geary

Edwards

et al. 2019

Contemporary Clinical Trials Communications

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Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.

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Section: Discussionmentioning

confidence: 99%

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

Murea

Geary

Edwards

et al. 2019

Contemporary Clinical Trials Communications

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“…These studies were heterogeneous (hazard ratio, 0.27-2.01; I 2 statistic as high as 94.3%), and all were database studies. Iyasere and Brown highlighted in their editorial (19) that these studies did not adjust for frailty, a strong predictor of mortality and a common indication for PD. They noted that in France, where frail patients aged $75 years are preferentially offered assisted PD, median survival was 2 years, similar to that in the corresponding cohort in the United Kingdom, which is largely on HD, suggesting no large survival difference between PD and HD across the English Channel (20).…”

Section: The Survival Battle Begins: Pd Versus Hdmentioning

confidence: 99%

Survival by Dialysis Modality—Who Cares?

Lee

Bargman

2016

CJASN

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In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.

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“…Clinicians can access several recommended tools to predict prognosis in elderly patients with advanced renal failure [9]. While these prognostic tools often consider survival, they may not predict quality of life or other outcomes, which may arguably be more important in these elders' lives [10]. The intrusive nature of dialysis treatment alters multiple aspects of daily life, including the effects on physical and cognitive states, and the worsening of the complexities of ageing [11].…”

Section: Introductionmentioning

confidence: 99%

Enabling good outcomes in older adults on dialysis: a qualitative study

et al. 2020

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Background: Older patients on dialysis may not have optimal outcomes, particularly with regards to quality of life. Existing research is focused mainly on survival, with limited information about other outcomes. Such information can help in shared decision-making around dialysis initiation; it can also be used to improve outcomes in patients established on dialysis. We used qualitative research methods to explore patient perspectives regarding their experience and outcomes with dialysis. Methods: Semi-structured interviews with participants aged ≥70, receiving dialysis at a regional Australian hospital, were recorded and transcribed. From participants' responses, we identified descriptive themes using a phenomenological approach, with verification by two researchers. Factors affecting outcomes were derived reflexively from these themes. Results: Seventeen interviews were analysed prior to saturation of themes. Participants (12 on haemodialysis, 5 on peritoneal dialysis) had spent an average of 4.3 years on dialysis. There were 11 males and 6 females, with mean age 76.2 years (range 70 to 83). Experiences of dialysis were described across four domains-the self, the body, effects on daily life and the influences of others; yielding themes of (i) responses to loss (of time, autonomy, previous life), (ii) responses to uncertainty (variable symptoms; unpredictable future; dependence on others), (iii) acceptance / adaptation (to life on dialysis; to ageing) and (iv) the role of relationships / support (family, friends and clinicians). Conclusions: Older patients experience the effects of dialysis across multiple domains in their lives. They endure feelings of loss and persistent uncertainty, but may also adapt successfully to their new circumstances, aided by the support they receive from family, health professionals and institutions. From these insights, we have suggested practical measures to improve outcomes in older patients.

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Mortality in the Elderly on Dialysis

Cited by 18 publications

References 19 publications

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

Survival by Dialysis Modality—Who Cares?

Enabling good outcomes in older adults on dialysis: a qualitative study

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