Beyond the Guidelines
4 August 2020

Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Publication: Annals of Internal Medicine
Volume 173, Number 3

Abstract

About 15% of adults in the United States—37 million persons—have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts—a nephrologist and a general internist–palliative care physician—reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

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Supplemental Material

Supplement. Beyond the Guidelines: Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia (slide set)

References

1.
Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2019. Accessed at www.cdc.gov/kidneydisease/publications-resources/2019-national-facts.html?utm_source=miragenews&utm_medium=miragenews&utm_campaign=news on 6 January 2020.
2.
Summary of recommendation statements. Kidney Int Suppl (2011). 2013;3:5-14. [PMID: 25598998]
3.
United States Renal Data System. 2018 USRDS annual data report: epidemiology of kidney disease in the United States. Accessed at www.usrds.org/2018/download/2018_Volume_2_ESRD_in_the_US.pdf on 18 February 2020.
4.
National Kidney Foundation. KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis. 2015;66:884-930. [PMID: 26498416]  doi: 10.1053/j.ajkd.2015.07.015
5.
Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol. 2010;5:2380-3. [PMID: 21051749]  doi: 10.2215/CJN.07170810
6.
Fassett RGRobertson IKMace Ret al. Palliative care in end-stage kidney disease. Nephrology (Carlton). 2011;16:4-12. [PMID: 21175971]  doi: 10.1111/j.1440-1797.2010.01409.x
7.
Brown EChambers EJGermain Meds. Supportive Care for the Renal Patient. 2nd ed. Oxford Univ Pr; 2010.
8.
Brunori GViola BFMaiorca Pet al. How to manage elderly patients with chronic renal failure: conservative management versus dialysis. Blood Purif. 2008;26:36-40. [PMID: 18182793]  doi: 10.1159/000110561
9.
Raghavan DHolley JL. Conservative care of the elderly CKD patient: a practical guide. Adv Chronic Kidney Dis. 2016;23:51-6. [PMID: 26709063]  doi: 10.1053/j.ackd.2015.08.003
10.
Chapter 5: referral to specialists and models of care. Kidney Int Suppl (2011). 2013;3:112-119. [PMID: 25599001]
11.
The Kidney Failure Risk Equation. Accessed at https://kidneyfailurerisk.com on 18 February 2020.
12.
Tangri NGrams MELevey ASet alCKD Prognosis Consortium. Multinational assessment of accuracy of equations for predicting risk of kidney failure: a meta-analysis. JAMA. 2016;315:164-74. [PMID: 26757465]  doi: 10.1001/jama.2015.18202
13.
Lønning KMidtvedt KLeivestad Tet al. Are octogenarians with end-stage renal disease candidates for renal transplantation? Transplantation. 2016;100:2705-2709. [PMID: 27861296]
14.
Segall LNistor IVanBiesen Wet al. Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence. Nephrol Dial Transplant. 2017;32:41-49. [PMID: 26673908]  doi: 10.1093/ndt/gfv411
15.
Lee TQian JThamer Met al. Tradeoffs in vascular access selection in elderly patients initiating hemodialysis with a catheter. Am J Kidney Dis. 2018;72:509-518. [PMID: 29784614]  doi: 10.1053/j.ajkd.2018.03.023
16.
Xue JLDahl DEbben JPet al. The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis. 2003;42:1013-9. [PMID: 14582045]
17.
Fluck RJFouque DLockridge RS Jr. Nephrologists' perspectives on dialysis treatment: results of an international survey. BMC Nephrol. 2014;15:16. [PMID: 24428875]  doi: 10.1186/1471-2369-15-16
18.
McAdams-DeMarco MADaubresse MBae Set al. Dementia, Alzheimer's disease, and mortality after hemodialysis initiation. Clin J Am Soc Nephrol. 2018;13:1339-1347. [PMID: 30093374]  doi: 10.2215/CJN.10150917
19.
Rakowski DACaillard SAgodoa LYet al. Dementia as a predictor of mortality in dialysis patients. Clin J Am Soc Nephrol. 2006;1:1000-5. [PMID: 17699319]
20.
Cohen LMRuthazer RMoss AHet al. Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol. 2010;5:72-9. [PMID: 19965531]  doi: 10.2215/CJN.03860609
21.
O'Connor NRKumar P. Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med. 2012;15:228-35. [PMID: 22313460]  doi: 10.1089/jpm.2011.0207
22.
Kurella Tamura MCovinsky KEChertow GMet al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539-47. [PMID: 19828531]  doi: 10.1056/NEJMoa0904655
23.
Chandna SMDa Silva-Gane MMarshall Cet al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26:1608-14. [PMID: 21098012]  doi: 10.1093/ndt/gfq630
24.
Da Silva-Gane MWellsted DGreenshields Het al. Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Clin J Am Soc Nephrol. 2012;7:2002-9. [PMID: 22956262]  doi: 10.2215/CJN.01130112
25.
MacPhail AIbrahim JEFetherstonhaugh Det al. The overuse, underuse, and misuse of dialysis in ESKD patients with dementia. Semin Dial. 2015 Sep-Oct;28:490-6. [PMID: 25997680]  doi: 10.1111/sdi.12392
26.
Murea MMoossavi SGarneata Let al. Narrative review of incremental hemodialysis. Kidney Int Rep. 2020;5:135-148. [PMID: 32043027]  doi: 10.1016/j.ekir.2019.11.014
27.
Depner TA. Uremic toxicity: urea and beyond. Semin Dial. 2001 Jul-Aug;14:246-51. [PMID: 11489197]
28.
Grubbs V. Time to recast our approach for older patients with ESRD: the best, the worst, and the most likely [Editorial]. Am J Kidney Dis. 2018;71:605-607. [PMID: 29685211]  doi: 10.1053/j.ajkd.2018.02.002
29.
Zimmermann CJJhagroo RAWakeen Met al. Opportunities to improve shared decision making in dialysis decisions for older adults with life-limiting kidney disease: a pilot study. J Palliat Med. 2020;23:627-634. [PMID: 31930929]  doi: 10.1089/jpm.2019.0340
30.
Ladin KPandya RKannam Aet al. Discussing conservative management with older patients with CKD: an interview study of nephrologists. Am J Kidney Dis. 2018;71:627-635. [PMID: 29396240]  doi: 10.1053/j.ajkd.2017.11.011
31.
Davison SNJhangri GSHolley JLet al. Nephrologists' reported preparedness for end-of-life decision-making. Clin J Am Soc Nephrol. 2006;1:1256-62. [PMID: 17699356]
32.
Combs SACulp SMatlock DDet al. Update on end-of-life care training during nephrology fellowship: a cross-sectional national survey of fellows. Am J Kidney Dis. 2015;65:233-9. [PMID: 25245300]  doi: 10.1053/j.ajkd.2014.07.018
33.
Eneanya NDWenger JBWaite Ket al. Racial disparities in end-of-life communication and preferences among chronic kidney disease patients. Am J Nephrol. 2016;44:46-53. [PMID: 27351650]  doi: 10.1159/000447097
34.
Freidin NO'Hare AMWong SPY. Person-centered care for older adults with kidney disease: core curriculum 2019. Am J Kidney Dis. 2019;74:407-416. [PMID: 30982551]  doi: 10.1053/j.ajkd.2019.01.038
35.
Tavares AR JrVieira CPSouza PA. Functional status of elderly adults receiving dialysis [Letter]. N Engl J Med. 2010;362:468-9; author reply 469. [PMID: 20162766]
36.
Carson RCJuszczak MDavenport Aet al. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol. 2009;4:1611-9. [PMID: 19808244]  doi: 10.2215/CJN.00510109
37.
Chandna SMSchulz JLawrence Cet al. Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity. BMJ. 1999;318:217-23. [PMID: 9915728]
38.
Murtagh FEMarsh JEDonohoe Pet al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007;22:1955-62. [PMID: 17412702]
39.
Joly DAnglicheau DAlberti Cet al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol. 2003;14:1012-21. [PMID: 12660336]
40.
Smith CDa Silva-Gane MChandna Set al. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract. 2003;95:c40-6. [PMID: 14610329]
41.
Wachterman MWO'Hare AMRahman OKet al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019;179:987-990. [PMID: 31009039]  doi: 10.1001/jamainternmed.2019.0125
42.
Burns ADavenport A. Functional status of elderly adults receiving dialysis [Letter]. N Engl J Med. 2010;362:468; author reply 469.  doi: 10.1056/NEJMc0911236
43.
Murtagh FEAddington-Hall JMHigginson IJ. End-stage renal disease: a new trajectory of functional decline in the last year of life. J Am Geriatr Soc. 2011;59:304-8. [PMID: 21275929]  doi: 10.1111/j.1532-5415.2010.03248.x
44.
Jassal SVChiu EHladunewich M. Loss of independence in patients starting dialysis at 80 years of age or older [Letter]. N Engl J Med. 2009;361:1612-3. [PMID: 19828543]  doi: 10.1056/NEJMc0905289
45.
Morton RLSnelling PWebster ACet al. Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease. CMAJ. 2012;184:E277-83. [PMID: 22311947]  doi: 10.1503/cmaj.111355
46.
De Biase VTobaldini OBoaretti Cet al. Prolonged conservative treatment for frail elderly patients with end-stage renal disease: the Verona experience. Nephrol Dial Transplant. 2008;23:1313-7. [PMID: 18029376]
47.
Yong DSKwok AOWong DMet al. Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care. Palliat Med. 2009;23:111-9. [PMID: 19153131]  doi: 10.1177/0269216308101099
48.
Wolfgram DF. Intradialytic cerebral hypoperfusion as mechanism for cognitive impairment in patients on hemodialysis. J Am Soc Nephrol. 2019;30:2052-2058. [PMID: 31511363]  doi: 10.1681/ASN.2019050461
49.
Murray AM. Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden. Adv Chronic Kidney Dis. 2008;15:123-32. [PMID: 18334236]  doi: 10.1053/j.ackd.2008.01.010
50.
McCusker JCole MAbrahamowicz Met al. Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc. 2001;49:1327-34. [PMID: 11890491]
51.
Francis J. Delirium in older patients. J Am Geriatr Soc. 1992;40:829-38. [PMID: 1634729]
52.
Charles CWhelan TGafni A. What do we mean by partnership in making decisions about treatment? BMJ. 1999;319:780-2. [PMID: 10488014]
53.
Charles CGafni AWhelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49:651-61. [PMID: 10452420]
54.
Wong SPYBoyapati SEngelberg RAet al. Experiences of US nephrologists in the delivery of conservative care to patients with advanced kidney disease: a national qualitative study. Am J Kidney Dis. 2020;75:167-176. [PMID: 31570175]  doi: 10.1053/j.ajkd.2019.07.006
55.
Scherer JSWright RBlaum CSet al. Building an outpatient kidney palliative care clinical program. J Pain Symptom Manage. 2018;55:108-116.e2. [PMID: 28803081]  doi: 10.1016/j.jpainsymman.2017.08.005
56.
Aldridge Carlson MDBarry CLCherlin EJet al. Hospices' enrollment policies may contribute to underuse of hospice care in the United States. Health Aff (Millwood). 2012;31:2690-8. [PMID: 23213153]  doi: 10.1377/hlthaff.2012.0286
57.
Aldridge MDBradley EH. Epidemiology and patterns of care at the end of life: rising complexity, shifts in care patterns and sites of death. Health Aff (Millwood). 2017;36:1175-1183. [PMID: 28679803]  doi: 10.1377/hlthaff.2017.0182
58.
Casarett DJFishman JMLu HLet al. The terrible choice: re-evaluating hospice eligibility criteria for cancer. J Clin Oncol. 2009;27:953-9. [PMID: 19114698]  doi: 10.1200/JCO.2008.17.8079
59.
Wachterman MWHailpern SMKeating NLet al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med. 2018;178:792-799. [PMID: 29710217]  doi: 10.1001/jamainternmed.2018.0256
60.
Arnold RMZeidel ML. Dialysis in frail elders—a role for palliative care [Editorial]. N Engl J Med. 2009;361:1597-8. [PMID: 19828538]  doi: 10.1056/NEJMe0907698

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 173Number 34 August 2020
Pages: 217 - 225

History

Published online: 4 August 2020
Published in issue: 4 August 2020

Keywords

Authors

Affiliations

Risa B. Burns, MD, MPH
Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
Sushrut S. Waikar, MD, MPH https://orcid.org/0000-0003-4004-326X
Boston University Medical Center, Boston, Massachusetts (S.S.W.)
Melissa W. Wachterman, MD, MPH, MSc
VA Boston Healthcare System, Boston, Massachusetts (M.W.W.)
Zahir Kanjee, MD, MPH
Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
Acknowledgment: The authors thank the patient and his daughter for sharing their story.
Grant Support: Beyond the Guidelines receives no external support.
Disclosures: Dr. Waikar reports personal fees from Public Health Advocacy Institute, CVS, Roth Capital Partners, Kantum Pharma, Mallinckrodt, Wolters Kluwer, GE Healthcare, GSK, Mass Medical International, Baron and Budd (vs. Fresenius), Johnson & Johnson, Venbio, Strataca, Takeda, Cerus, Pfizer, Bunch and James, and Harvard Clinical Research Institute (Baim Institute) and grants and personal fees from Allena Pharmaceuticals outside the submitted work. Dr. Wachterman reports grant funding from the National Institute on Aging during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2640.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Corresponding Author: Risa B. Burns, MD, MPH, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail, [email protected].
Current Author Addresses: Drs. Burns and Kanjee: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Dr. Waikar: Nephrology Section, Boston University School of Medicine and Boston Medical Center, 650 Albany Street, EBRC5, Boston, MA 02118.
Dr. Wachterman: Section of General Medicine, VA Boston Healthcare System, Building 9 (152G), 150 South Huntington Avenue, Boston, MA 02130.

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Risa B. Burns, Sushrut S. Waikar, Melissa W. Wachterman, et al. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med.2020;173:217-225. [Epub 4 August 2020]. doi:10.7326/M20-2640

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