The findings support more holistic and age-appropriate care for older Australians.
Older patients with severe chronic kidney disease are more likely to die from factors other than renal failure, suggesting more holistic care could improve outcomes.
The Tasmanian Chronic Kidney Disease study found that people over age 65 with stage 4 chronic kidney disease were likely to die before they developed kidney failure requiring dialysis or transplant. The study looked at a decade of data for almost 7,000 Tasmanians with incident stage 4 chronic kidney disease. While the risk of death increased with age, the risk of kidney failure within five years of diagnosis declined.
Before age 65, the risk of kidney failure within five years was 39% compared with 18% risk of death. Between 65 and 74, those numbers flipped. The risk of kidney failure dropped to 12% and the risk of dying went up to 39%. “Clinical guidelines should recognise these competing risks and include recommendations about holistic supportive care, not just on preparation for dialysis or transplantation,” the researchers said.
The study also found that men in all age groups had a higher chance of kidney failure than women, and that in people under 65, macroalbuminuria was associated with the highest risk of developing kidney failure.
The findings suggest guidelines should include options for “holistic care”, rather than just dialysis or transplantation, said the authors.
Lead author Professor Mathew Jose, professor of medicine at the University of Tasmania, told The Medical Republic that while current guidelines do not really take age into account it is likely GPs would.
“Whether you’re 40, or whether you’re 90, the guidelines are the guidelines. But GPs have always made their own common-sense decisions,” he said.
For example, many clinicians wouldn’t send their 90-year-old patient to the hospital for dialysis, he said.
“Even though kidney function is low, very few people will end up with actual kidney failure, especially if they’re over the age of 65,” he added. “The dialysis machine and the tertiary hospital is not necessarily the primary outcome for everybody.
“The best care is really about is what the patient’s priorities are,” said Professor Jose.
“Some people want everything done, all the tests. And other people don’t want a bar of us in the hospital. They just want to get on and live their life.”
Medical interventions can seriously affect the quality of life for patients with low kidney function. “Once you’re on dialysis, you come to us three days a week,” said Professor Jose. Supportive care and symptom management were important for everybody, Professor Jose explained. This is not about denying patients treatment, he pointed out, but about providing choice. Ongoing research suggests that for older people, there wasn’t much difference between time left to live and time spent away from medical care for those who opt for dialysis.
“We haven’t always had that sort of information. We’re starting to be able to describe what kidney failure and the end of life with kidney failure looks like to enable them to choose: do they want a machine or not? Because for some people, that extra six months might see them through to their 50th wedding anniversary, or their grandchild being born. So it’s not that we’re withholding a machine. It’s just a matter of, is that what they want?”
