# 006 Initiating Renal Replacement Therapy (RRT) in Geriatric Patients

Fast Facts and Concepts #006 PDF

Authors: Christopher J Anderson, Edmund Duthie MD, Bambi Wessel

Objectives:    

1. To review the current evidence based recommendations regarding when to initiate RRT in geriatric patients
2. To outline multiple methods  that can be used to evaluate a geriatric patient’s candidacy for RRT

Context:  Geriatric patient with end stage renal disease (ESRD)

Action: Initiating RRT in a geriatric patient with ESRD

Incidence/Prevalence:  Patients over the age of 65 constitute the fastest growing group of ESRD patients requiring dialysis.

Underlying Science: With aging there is a physiologic decline in glomerular filtration rate. This lack of reserve coupled with the prevalence of chronic illnesses associated with renal damage ( e.g., diabetes, hypertension, atherosclerotic vascular disease) can result  in renal impairment in elderly  people. In 2006, the United States National Kidney Foundation (NKF) work group updated the guidelines for initiation of hemodialysis  and stated that “at CKD Stage  5, when the estimated Glomerular Filtration Rate  (eGFR ) is less than 15 ml/min per 1.73m2, nephrologists should evaluate the benefits, risks and disadvantages of beginning renal replacement therapy2. “

Between 1996 and 2005, the eGFR at the time of dialysis initiation has steadily increased in patients both with and without extensive co-morbidities at the time of dialysis.

Data from the United States Renal Data System (USRDS) showed a higher mortality risk for patients 65-74 years old with higher eGFR start times (table 1)2.  This may be due to accelerated loss of eGFR following initiation of dialysis.

Table 1

It is important to note that survival may be strongly influenced by co-morbidities such as vascular disease and cardiac disease. Once these are taken into account, age may not be an independent risk factor for increased mortality . This suggests that the characteristics of an individual patient are more important than chronologic age and is congruent with the NKF recommendations. Therefore, dialysis should not be withheld on the basis of age alone if otherwise appropriate.
                                                                                                    
Assessment: The  data above does not support early initiation of RRT in geriatric patients (Table 1). As the current NKF recommendations for initiating RRT in a geriatric patient are somewhat vague, it has been proposed that a complete in depth quality of life (QOL) assessment is the best tool to evaluate the geriatric patient’s candidacy for RRT. Ideally, this would consist of a geriatric team evaluation of the patient including a baseline comprehensive geriatric assessment (CGA). Domains to be considered in a CGA are shown in Table 2. Subsequent CGA’s can be useful in making important medical decisions, including if/when to initiate RRT. For the non-geriatrician, many screening tools exist to evaluate a geriatric patient’s QOL and functional ability (Table 2). It is important to remember that dialysis, like any medical resource, will have candidates that range from excellent to poor based not exclusively on age but, on current QOL and prospective QOL maintenance/improvements.
 

Table 2 (adapted from reference 1)

• Healthy/Usual: The most optimal dialysis patient who might also be a transplant candidate.
   
• Vulnerable: A more typical dialysis candidate. Geriatric assessment and intervention plans (e.g., rehabilitation, pain control, treatment of cognitive deficits and depression, limiting polypharmacy, preventing falls, instituting home services) may slow the progression of geriatric susceptibility factors that will adversely effect prognosis, QOL, and the dialysis experience.
   
• Frail: This is a suboptimal dialysis candidate and should be considered for a non-dialytic treatment plan or a time-limited dialysis trial. Final decisions will hinge on patient preferences, QOL, and contextual issues.

Nursing home (NH) patients typically might reflect the frail group outlined in Table 2.  Among a national cohort of NH residents followed 12 months after the initiation of dialysis, 58% had died and pre-dialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status; this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial, even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.³

In conclusion, geriatric patients with ESRD should be assessed using functional measures and geriatric assessment principles.  Patient prognosis should be estimated based on this assessment and discussions held about therapeutic options, including foregoing dialysis when the benefits are not clear.⁴  
 

ACGME Competencies: Medical Knowledge, Patient Care, Systems-based Practice, Interpersonal and Communication Skills
 

References:

1. American Society of Nephrologists Online Geriatric Curriculum http://www.asn-online.org/education/
2. Rosansky, SJ; Clark, WF; Eggers, P and Glassock, RJ. Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful? International Society of Nephrology, 2009.
3. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361:1539-1547.
4. Alexander R, Smith K, Williams BA, and Lo B.  Discussing Overall Prognosis with the Very Elderly. N Engl J Med 2011; 365:2149-2151.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Christopher J Anderson, Edmund Duthie MD, Bambi Wessel, Fast Fact #006: Initiating Renal Replacement Therapy (RRT) in Geriatric Patients, March, 2012

Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

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