A recent investigation revealed that frail elderly individuals who delayed starting dialysis lived on average only nine days less and enjoyed more time at home compared to those who initiated treatment right away.
The question of whether dialysis is the most suitable option for kidney failure, and when to begin it, might require more thoughtful evaluation, according to a recent study.
Researchers from Stanford Medicine discovered that for older patients not viable for a kidney transplant, beginning dialysis once their kidney function declined past a specific level granted them approximately an extra week of life.
More importantly, they spent around two additional weeks in hospitals or care facilities on top of the time spent on dialysis.
“Is that really what a patient who is 75 or 80 years old wants to be doing?” questioned Maria Montez Rath, PhD, a senior research engineer.
Montez Rath, the primary author of a study addressing dialysis, life expectancy, and home time, is set to be published in Annals of Internal Medicine. Manjula Tamura, MD, a nephrology professor, is the senior author.
“It’s critical for all patients, especially older adults, to understand the trade-offs,” Tamura explained. “Patients and their doctors should thoroughly consider whether and when to start dialysis.”
Patients with kidney failure that are healthy enough may receive a transplant, which helps eliminate toxins and excess fluid from their blood. However, this option is often not available to many elderly patients who may also face other health issues like heart or lung diseases or cancer.
For these patients, doctors frequently recommend dialysis — a treatment that mimics the function of healthy kidneys — when they reach kidney failure. A patient is regarded as having kidney failure when their estimated glomerular filtration rate (eGFR), a gauge of kidney function, drops below 15.
According to Montez Rath, patients and their families often believe that dialysis is their sole option, or that it will significantly extend their lifespan. “They frequently consent to dialysis without truly grasping its implications.”
However, as Tamura pointed out, patients can substitute medications for dialysis to help manage symptoms like fluid buildup, itchiness, and nausea. She noted that dialysis can come with drawbacks, including cramping and fatigue, and generally necessitates a three- to four-hour clinic visit three times weekly.
“It’s quite an intensive treatment that requires a significant lifestyle adjustment,” she remarked.
Lifespan and home time
The researchers aimed to assess what dialysis means for older adults not eligible for a transplant: determining how much it extends life and the relative days spent in a healthcare facility such as a hospital, nursing home, or rehab center.
The team analyzed health records spanning from 2010 to 2018 for 20,440 patients (98% male) from the U.S. Department of Veterans Affairs. These patients were aged 65 and older, suffered from chronic kidney failure, were not being assessed for a transplant, and had an eGFR lower than 12.
By simulating a randomized clinical trial through electronic health records, they separated patients into two groups: those who began dialysis immediately and those who delayed it for at least a month. Over three years, about half of the patients in the delayed group never started dialysis.
Those who began dialysis right away lived an average of nine days longer than those who delayed, but spent 13 additional days in an inpatient facility. Age played a role: Patients aged 65 to 79 who initiated dialysis early lived, on average, 17 days fewer while spending 14 additional days in a care facility; patients aged 80 and above who started dialysis early lived on average 60 days longer but spent 13 more days in an inpatient setting.
Patients who never underwent dialysis passed away, on average, 77 days sooner than those who began dialysis immediately, yet they spent 14 more days at home.
“This study demonstrates that starting dialysis promptly may lead to longer survival, but also a significant commitment of time to dialysis treatments and an increased likelihood of hospitalization,” stated Montez Rath.
Tamura pointed out that doctors often suggest dialysis to provide patients with hope or because the downsides of the treatment haven’t always been clear. However, the study suggests that physicians and patients might want to wait until their eGFR decreases further, considering individual symptoms and preferences before starting dialysis.
“Each patient has unique goals,” she remarked. “For some, the option of dialysis feels like a blessing, while for others, it may feel burdensome.”
She added that it could be beneficial for healthcare providers to frame dialysis for frail, elderly patients as a palliative measure — mainly aimed at symptom relief.
“Currently, patients often perceive dialysis as a choice between life and death,” she stated. “When presented this way, patients don’t have the space to consider if the treatment aligns with their goals, leading them to overestimate its benefits. However, when framed as symptom-relief, patients can better comprehend the trade-offs involved.”
*Image credit: Emily Moskal/Stanford Medicine. It can only be utilized in an editorial context and not for any commercial, promotion, endorsement, advertising, or merchandising activities. It should only accompany a story regarding the research described in this article.
