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Previous Volume 361:1612-1613 October 15, 2009 Number 16 Next

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To the Editor: We report a negative effect of initiation of dialysis on independent living by patients 80 years of age or older. Using a single-center, retrolective cohort study design (involving data collected prospectively for a purpose not directly relate to the study), we followed the progress of all patients 80 years of age or older in whom long-term dialysis was initiated during the period 2000–2005. Patients with evidence of acute kidney injury were excluded. All patients were followed for a minimum of 1 year or until death. Changes in living status were prospectively recorded in a clinical database. Functional loss was defined as a permanent transfer to an assisted-living setting or nursing home or having submitted an application for caregiver support. Respite care or temporary placement in a nursing home was not recorded.

A total of 97 patients with a mean (±SD) age of 84.5±3.3 years (range, 80 to 96) underwent the initiation of long-term dialysis. Half of the patients were men. Most (90%) had been seen by a nephrologist for predialysis care, and 44% began with peritoneal dialysis. Seventy-five percent of the patients had multiple coexisting conditions with a mean modified Charlson score of 5.1±2.5.¹ (The score is calculated as the number of coexisting conditions, weighted according to their relative effects on mortality, with scores ranging from 0 to 33 and higher scores indicating a greater burden of illness.) A total of 69% (67 of 97) of patients started dialysis as inpatients (median period of hospitalization before dialysis, 6 days; interquartile range, 3 to 17). Of the 67 patients admitted for the initiation of dialysis, 31 (46%) had had more than 6 months of predialysis nephrology care, and 28 were deemed suitable candidates for and began peritoneal dialysis.

At the time of dialysis initiation, the majority of patients (76 of 97) were living at home with no assistance for the activities of daily living (Figure 1). A further 15 patients had assistance from a community or private caregiver. Within the first 6 months after dialysis was begun, more than 30% of patients had functional loss requiring community or private-caregiver support or transfer to a nursing home. Over the next 2 years, the number of patients who remained independent at home or who died while ordinarily residing at home remained relatively stable. Neither the use of hemodialysis versus peritoneal dialysis nor initiation of dialysis as an inpatient or outpatient was predictive of subsequent decline.

View larger version (26K): [in this window] [in a new window]   Figure 1. Living Status and Residence during the Study Period, Assessed at 6-Month Intervals. "Supported" was defined as being a resident in a full-time care setting or nursing home, "assisted" as being a resident in an assisted-care setting or receiving support from a community or private caregiver, and "independent" as residing in the home without support or assistance.

 
Previous studies indicate that less than 20% of frail, non–dialysis-dependent elderly patients have a disability or require nursing-home care within 18 months after hospital discharge.² Our data show considerably higher rates of onset of disability after dialysis is initiated, suggesting poor functional outcomes in relation to events occurring around the time of dialysis initiation. Studies using formal measures of functional change at the time of dialysis initiation are needed to appreciate the true extent of functional decline, as our data are likely to underestimate it.

Sarbjit Vanita Jassal, M.D.
University Health Network
Toronto, ON, Canada
vanita.jassal{at}uhn.on.ca

Ernest Chiu, B.M.Sc.
University of Toronto
Toronto, ON, Canada

Michelle Hladunewich, M.D.
Sunnybrook Health Sciences Centre
Toronto, ON, Canada

References

1. Hemmelgarn BR, Manns BJ, Quan H, Ghali WA. Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 2003;42:125-132. [CrossRef][Web of Science][Medline]
2. Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA 2004;292:2115-2124. [Free Full Text]

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