Re-thinking the value of dialysis for elderly patients with chronic kidney disease

14 October 2021• NEWSITEM

PhD student Wouter Verberne is interested in assessing the benefits of dialysis therapy for the elderly. Guided by LUMC Professor Willem Jan Bos, he compared the value of dialysis and so-called conservative care in advanced chronic kidney disease. His research is now being used to inform nephrology care in older patients. Verberne will defend his thesis on 14 of October.

Global burden of advanced chronic kidney disease (CKD) has increased considerably over the last decades, driven by a plethora of factors including obesity, diabetes, hypertension and ageing. At present, senior patients aged between 70 and 80 represent the largest and fastest growing group affected by the disease. As it causes kidney function to severely reduced over time, dialysis might be needed to filter the blood.

Default dialysis treatment

In this setting, dialysis is considered nowadays the default treatment pathway for older patients in countries like the Netherlands, United States and United Kingdom. “But it is an intensive therapy, which might not fit within the care goals of every individual.”, notes Wouter Verberne, internal medicine resident at the University Medical Center Utrecht (UMC Utrecht). Compared to younger patients, the elderly generally suffer from multiple disorders and are more frail. “This has raised a dilemma that underpins my research today: does dialysis really benefit all older patients?”.

Meaningful care options

Verberne conducted his studies under the guidance of Willem Jan Bos, Professor of Kidney Diseases and Outcomes of Care at Leiden University and doctor at the Internal Medicine department of the Leiden University Medical Center (LUMC). As a former student of Doctor Willem Kolff – inventor of the artificial kidney – Bos describes Kolff’s devotion towards understanding what constituted meaningful care for the individual patient: “He used to say ‘you should always have a joint discussion to define the advantages and disadvantages of an intensive treatment such as dialysis’”. Interestingly, Verberne observed during his research that many patients wanted to know about different therapy options”.

Conservative alternative

“Conservative care – consisting of actively treating patients with medications, diet and lifestyle advice – has been proposed as a potential alternative to dialysis. In this treatment pathway, the main goal is to preserve the individual’s quality of life with adequate symptom control rather than prolong their life per se”, explains Verberne. However, comparative data on both therapy outcomes is currently limited. “To determine the value of each treatment, I conducted a retrospective study, which included patients aged 70 years or older, with advanced chronic kidney disease, who received care between 2004 and 2016 at the St Antonius Hospital, and had made an explicit decision in favor of dialysis or conservative care”.

The researcher demonstrated that – overall – older patients who opted for dialysis lived longer, but the increase in life-years for those aged above 80 or with multiple diseases was not significant. “Meanwhile, quality of life appeared to be similar between both patient groups, and therapy burden and costs were significantly lower for patients who opted for conservative care. The conservative approach is, thus, an appropriate care alternative for the elderly”. Verberne’s study is now being used to inform nephrology guidelines in the Netherlands and Europe.

Shared decision-making

Bos highlights the importance of sharing the treatment decision-making process in the consultation room: “Healthcare providers need to look beyond what is considered advantageous solely from a medical perspective, and also take into account what the individual’s life goals are”. He reiterates that all available options – including conservative care – should be talked about openly. “Patients must be informed that choosing not to initiate dialysis will be taken seriously, and that it is possible to extend survival time and quality of life through appropriate symptom, diet and medication management”.

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