SP568WHAT IS THE BENEFIT OF DIALYSIS IN FRAIL ELDERLY PATIENTS?

Abstract

Introduction and Aims: It is unclear whether dialysis can extend life in frail elderly patients or in which subgroups the burden balances the advantages. We therefore undertook a review of the literature around the benefits of dialysis in the frail & elderly to produce guidelines to support shared decision-making on this difficult clinical decision. Methods: A systematic literature review from 1990 to 2015 identified 853 potentially relevant papers, none of them RCTs. 13 comparative cohort studies (conservative management [CM] vs dialysis), 5 cohort studies of CMalone in advanced CKD and 2 systematic reviews fulfilled the search criteria. Studies of cohorts of elderly and/or frail patients receiving dialysis with no comparator were excluded as these are well reported by Registries. Results: Our review identified studies of variable size and quality totalling 1245 patients having received CM and 2338 patients having received dialysis or on dialysis pathway. Patients receiving CM were in general older, more co-morbid & of poorer functional status than dialysis-destined patients. All studies were confounded by lack of a clear definition of CM, & lack of clear criteria from which to measure survival between cohorts. Patient groups were defined by differing ages & levels of renal function at recruitment. The allocation of patients to CMor dialysis was by shared decision-making in most studies. Most studies measured survival, & in comparative studies of CM& dialysis, choosing dialysis is associated with increased survival but in all studies where this could be identified the survival advantage was lost with increasing age & co-morbidity. Frailty was only defined & measured in one study & was more prevalent in CM patients, & frailty progressed as CKD progressed in both CM & dialysis groups. Quality of life (QoL) scores were measured in 4 studies showing reduced physical but similar mental components for CM patients compared to dialysis. Symptom burden was addressed in only 2 studies showing high levels in both groups but worse in CM patients. Neither QoL nor symptom burden scores were improved by chronic dialysis & indeed temporarily worsened at dialysis initiation. In one study, anxiety was higher in CM patients but depression comparable between CM & dialysis. Access to palliative care, death outside hospital & likelihood of invasive treatments were worse in dialysis patients. Conclusions: The data to support decision-making between dialysis or CMfor frail, elderly patients with advanced CKD is based on observational studies of variable quality. All studies are confounded by multiple issues including a lack of clear definition of CM & clear criteria for measurement of survival. However, all studies show reducing benefit in terms of longevity with increasing age & co-morbidity & reduced functional capacity. Offering CM to frail and/or elderly patients with advanced CKD is a viable alternative to dialysis which would not reduce longevity for many patients & would increase access to palliative care services at end of life. The evidence base for managing frail elderly patients with advanced CKD is poor. There is a need for an agreed definition of CM including its components & minimum standards. There is an overwhelming need for a robust assessment of outcomes including survival, QoL, symptom burden, treatment burden, nutritional & functional trajectory in elderly frail patients treated by dialysis or by CM.