"Certainly, the factors that contribute to early dialysis initiation are complex and may not always be clinical. But again, it makes you think that perhaps some of these patients are not started early because they have symptoms, but for other reasons, and perhaps it’s just the nervousness of the nephrologist caring for a very frail patient," she commented.
Indeed, urgent indications accounted for just 10% of the patients in the late-start arm of the IDEAL study who ended up initiating dialysis at greater than the target eGFR, with "uremia" and "physician discretion" accounting for 80%. However, Dr. Tamura pointed out, the uremic syndrome can be difficult to diagnose in elderly patients with other chronic conditions. No biomarker is sufficiently specific, and symptoms of uremia can overlap with other conditions. For example, nausea may result from diabetic gastroparesis, fatigue may be from cardiopulmonary disease or depression, and cognitive impairment might be cause by medications or dementia.
Moreover, conditions commonly observed in advanced chronic kidney disease – such as malnutrition, low functional status, pruritis, and restless leg syndrome – not always improve with dialysis initiation.
Also complicating the decision of when to initiate dialysis in the elderly is the fact that estimated equations for GFR tend to be less accurate in the elderly due to sarcopenia and fluid retention, and that acute kidney injury is more common in older patients, she said.
Given all this, Dr. Tamura advises that it is appropriate to delay dialysis initiation in older asymptomatic adults with an eGFR greater than 10 mL/min. As for when it is appropriate to initiate dialysis, "there are still more questions than answers. Clinical judgment will continue to guide practice, but hopefully symptom burden and patient preferences will have a stronger influence."
Dr. Tamura reported having no conflicts of interest.