The challenges of renal replacement therapy and renal palliative care in the elderly

Abstract

The main aim of this review is to let general practitioners and physicians understand what happens to older patients after referral to the renal service. Usually, most patients will be managed completely by the renal team, either because the patient requires dialysis or because conservative but specialised care is appropriate. The recent increase in dialysis rate can mostly be accounted for by older patients for whom such demanding treatment was previously thought to be contraindicated. The decision to dialyse the elderly still remains difficult, with recent data suggesting that if there are significant comorbidities the survival advantage of dialysis in patients over 75 years of age is unlikely to be more than four months. Towards the end of life, conservative treatment is not simply a decision not to dialyse, but comprises active disease management, including treatment of anaemia and other supportive care, which may become increasingly complex, e.g. pain relief with fentanyl and alfentanyl. Older patients who decide to accept dialysis treatment contend with all the usual end of life issues of older people. They have an additional option, denied to the rest of us, of dialysis withdrawal; this effectively allows them to die at a time of their choosing.

Outcome of dialysis patients aged seventy years or above – a retrospective analysis

“…Another important aspect, which has to be taken into account, is that -due to the fact of the retrospective single-centre study design -only medical issues were analysed, disregarding the patient's view of quality of life. Further, the study did not differentiate between patients with a high or low comorbidity rate in the anaylsis of survival, which could hide eventual influences on patient's survival during haemodialysis, as other studies claim [18,23,34]. In addition, there might be a positive selection in the senior population due to the fact that the very ill patients with ESRD underwent conservative therapy and did not start haemodialysis.…”

“…Furthermore, most of the patients who withdrew from haemodia-lysis may be hidden within that category of death. In literature, withdrawal of haemodialysis is a very common cause of death, especially in older patients [18,[23][24][25]. However, this study was not performed to investigate withdrawal of haemodialysis as a direct cause of death.…”

Approach to the management of end-stage renal disease

“…Close liaison between renal, palliative and primary care services has developed in recent years to improve this aspect of patient care. 11,20 …”

Biosimilar Esas: A Comparative Review

“…Caring for patients with kidney disease is typically a long-term commitment with unique risks and challenges for healthcare professionals (HCPs) including actively managing the disease, such as treatment of anaemia with erythropoietin-stimulating agents (ESAs) and intravenous (IV) iron and involving patients and their families in treatment decisions whilst working with multidisciplinary teams effectively (Isles et al 2011). Nurses have a pivotal role in patient care, not only administering medications but also monitoring response and educating patients about their medication.…”