Dialysis Linked to Functional Decline in Nursing Home Residents With End-Stage Renal Disease
By Laurie Barclay, MD
Medscape Medical News
October 14, 2009 — In nursing home residents with end-stage renal disease (ESRD), starting dialysis is linked to functional decline, according to the results of an uncontrolled study reported in the October 15 issue of the New England Journal of Medicine.
"It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with...ESRD," write Manjula Kurella Tamura, MD, MPH, from Stanford University School of Medicine in Palo Alto, California, and colleagues. "We studied the trajectory of functional status before and after the initiation of dialysis among elderly nursing home residents with ESRD. We aimed to evaluate the frequency of short-term and long-term maintenance of functional status after the initiation of dialysis and to estimate the effect of the initiation of dialysis on the trajectory of functional status."
The investigators identified all 3702 US nursing home residents who started dialysis between June 1998 and October 2000 and who had at least 1 measurement of functional status before dialysis started, using a national registry of dialysis patients linked to a national registry of nursing home residents. Functional status for 7 activities of daily living was scored with the Minimum Data Set-Activities of Daily Living scale (0 - 28 points, with higher scores indicating greater functional dependence).
During the 3 months before dialysis began, median Minimum Data Set-Activities of Daily Living score was 12 points, and this increased to 16 points during the 3 months after dialysis was started. Functional status was maintained in 39% of nursing home residents at 3 months after dialysis began, but by 12 months, 58% had died and only 13% maintained predialysis functional status.
Starting dialysis was associated with a sharp decline in functional status, reflected in an increase of 2.8 points in the Minimum Data Set-Activities of Daily Living score (95% confidence interval [CI], 2.5 - 3.0 points), In a random-effects model, the functional decline was independent of age, sex, race, and functional-status trajectory before dialysis was started. After adjustment for the presence or absence of an accelerated functional decline during the 3-month period before dialysis was started, the decline in functional status associated with dialysis was 1.7 points (95% CI, 1.4 - 2.1 points).
"Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status," the study authors write. "Efforts to address the goals of care, control symptomatic distress, and provide supportive care for disability are critical in this population, regardless of whether dialysis is started."
Limitations of this study include lack of a control group of nursing home residents with ESRD who did not start treatment with dialysis, preventing determination of whether dialysis was the cause of functional decline and, if so, to what extent, or whether dialysis might actually improve life expectancy. In addition, clinical events occurring when dialysis started and the reasons for starting dialysis could not be determined, and there were no serial estimated glomerular filtration rates before dialysis was started.
In an accompanying editorial, Robert M. Arnold, MD, from the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania, and Mark L. Zeidel, MD, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts, note that randomized trials are lacking to evaluate the benefits of dialysis in the elderly population.
"Prospective studies to define predictors of good outcomes in the population of patients undergoing dialysis are urgently needed," Drs. Arnold and Zeidel write. "In persons who will benefit, we must determine when we should initiate dialysis; this may differ substantially from the initiation of dialysis in younger, healthier patients with ESRD. Finally, we must learn much more about how to ensure that we obtain truly informed consent from our patients, how to support them optimally in their therapeutic decisions, and how to relieve their symptoms most effectively."
The National Institute of Aging, the National Center for Research Resources, and the National Institute of Diabetes and Digestive and Kidney Diseases supported this study. Some of the study authors have disclosed various financial relationships with Amgen, AMAG Pharma, Biogen Idec, Triaxis Medical Devices, and/or Ardelyx. The reported data were provided by the US Renal Data System, but the interpretation and reporting of these data are the responsibility of the study authors and do not reflect an official policy or interpretation of the US government.
The editorialists have disclosed no relevant financial relationships.
