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Beginning Dialysis in Nursing Home ESRD Patients Marks Decline


End stage renal disease (ESRD) is defined by permanent loss of function of the kidneys to less than 10% of normal capacity. The two main causes of ESRD in the United States are diabetes and hypertension.

Patients with ESRD need to have their dialysis either on a permanent basis or until a kidney transplant can be done. Dialysis is done to remove the toxins from the body that would normally be removed by the filtering systems of the healthy kidney.

A growing number of elderly Americans with ESRD are starting dialysis, and nursing home residents account for 4% of new ESRD patients and 11% of new ESRD patients over the age of 70.

Manjula Kurella Tamura, MD, MPH, from Stanford University School of Medicine in Palo Alto, California, and colleagues looked at how dialysis affected the function of ESRD patients in nursing home residents. The results of their uncontrolled study, published in the October issue of the New England Journal of Medicine, showed that starting dialysis is linked to functional decline in the ESRD nursing home patients.

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The researchers used the national registry of dialysis patients to identify 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. 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). The functional ability of the patients was measured at 3, 6, 9 and 12 months after beginning dialysis.

The median Minimum Data Set-Activities of Daily Living score increased from 12 points three months prior to beginning dialysis 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. Only 13% remained at their predialysis functional status. Within 12 months, 58% had died.

The decline of function was found to be independent of age, sex, race, and functional-status trajectory before dialysis was started.

Tamura and colleagues noted "Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 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.

Tamura K, et al "Functional Status of Elderly Adults before and after Initiation of Dialysis" N Engl J Med 2009; 361: 1539-47
Arnold M and Zeidel M "Dialysis in Frail Elders -- A Role for Palliative Care" N Engl J Med 2009; 361: 1597-98