Optimizing Renal Replacement Therapy in Older Adults
Optimizing Renal Replacement Therapy in Older Adults
It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.
There is substantial variation in the type and intensity of care provided to older patients with end-stage renal disease (ESRD), stemming from uncertainty about the benefits and harms of ESRD treatment strategies in this growing population. Many older patients starting dialysis have multiple chronic conditions in addition to ESRD. As comorbidity accumulates, average life expectancy, functional status, and quality of life decline. However, there is considerable heterogeneity in both life expectancy and treatment preferences among older patients. This heterogeneity makes it difficult to synthesize information about the risks and benefits of recommended interventions for individual patients.
Clinical practice guidelines for ESRD care have traditionally taken an age-neutral approach, allowing clinicians flexibility to adapt guidelines to individual patients, but providing little guidance about how to do this. Quality improvement initiatives in ESRD care advocate for quality benchmarks, but often fail to identify patients who may not benefit from the standard of care. Some have noted that both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing patients with multiple chronic conditions, or the value that patients place on achieving these outcomes.
For example, although it may be intuitive that older patients on average derive less benefit than their younger counterparts from interventions like kidney transplantation, some older patients may derive substantial benefit, whereas others will not benefit at all and may even be harmed. For interventions such as hypertension treatment, older adults have a higher absolute risk of cardiovascular events but also a higher risk of adverse events from treatment. Reconciling these competing factors to make treatment decisions is often complex and the resulting uncertainty can lead to both under- and overtreatment of older adults.
Clinicians must also prioritize these treatment decisions (e.g., by prioritizing the kidney transplant evaluation, there may be less time for home dialysis training). Integrating treatment preferences with considerations of risks and benefits is central to individualized decision-making because it allows patients to prioritize the outcomes that matter to them.
We propose a conceptual framework to guide management decisions for older patients with ESRD. Our framework is adapted from a framework proposed for cancer screening in the elderly that considers three factors: life expectancy, the benefits and harms of competing treatment strategies, and the patient's preferences. We apply this framework to three aspects of decision-making for older patients with (or expected to develop) ESRD: selection of a dialysis modality, choice of vascular access for hemodialysis (HD), and referral for kidney transplantation. Using available data, we provide quantitative estimates to compare treatment strategies in older patients with different life expectancies. Although there are several established methods for quantifying an intervention's benefits or risks, we use the number needed to treat (NNT), the reciprocal of the absolute risk reduction. There is no one value for the NNT that defines a beneficial intervention; however the closer to 1 the NNT then the larger the benefit. Details of the data sources and the computational methods are provided in the Supplementary Information online. Using this framework, we illustrate how clinicians could more effectively tailor treatment strategies to individual ESRD patients by combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences.
Abstract and Introduction
Abstract
It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.
Introduction
There is substantial variation in the type and intensity of care provided to older patients with end-stage renal disease (ESRD), stemming from uncertainty about the benefits and harms of ESRD treatment strategies in this growing population. Many older patients starting dialysis have multiple chronic conditions in addition to ESRD. As comorbidity accumulates, average life expectancy, functional status, and quality of life decline. However, there is considerable heterogeneity in both life expectancy and treatment preferences among older patients. This heterogeneity makes it difficult to synthesize information about the risks and benefits of recommended interventions for individual patients.
Clinical practice guidelines for ESRD care have traditionally taken an age-neutral approach, allowing clinicians flexibility to adapt guidelines to individual patients, but providing little guidance about how to do this. Quality improvement initiatives in ESRD care advocate for quality benchmarks, but often fail to identify patients who may not benefit from the standard of care. Some have noted that both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing patients with multiple chronic conditions, or the value that patients place on achieving these outcomes.
For example, although it may be intuitive that older patients on average derive less benefit than their younger counterparts from interventions like kidney transplantation, some older patients may derive substantial benefit, whereas others will not benefit at all and may even be harmed. For interventions such as hypertension treatment, older adults have a higher absolute risk of cardiovascular events but also a higher risk of adverse events from treatment. Reconciling these competing factors to make treatment decisions is often complex and the resulting uncertainty can lead to both under- and overtreatment of older adults.
Clinicians must also prioritize these treatment decisions (e.g., by prioritizing the kidney transplant evaluation, there may be less time for home dialysis training). Integrating treatment preferences with considerations of risks and benefits is central to individualized decision-making because it allows patients to prioritize the outcomes that matter to them.
We propose a conceptual framework to guide management decisions for older patients with ESRD. Our framework is adapted from a framework proposed for cancer screening in the elderly that considers three factors: life expectancy, the benefits and harms of competing treatment strategies, and the patient's preferences. We apply this framework to three aspects of decision-making for older patients with (or expected to develop) ESRD: selection of a dialysis modality, choice of vascular access for hemodialysis (HD), and referral for kidney transplantation. Using available data, we provide quantitative estimates to compare treatment strategies in older patients with different life expectancies. Although there are several established methods for quantifying an intervention's benefits or risks, we use the number needed to treat (NNT), the reciprocal of the absolute risk reduction. There is no one value for the NNT that defines a beneficial intervention; however the closer to 1 the NNT then the larger the benefit. Details of the data sources and the computational methods are provided in the Supplementary Information online. Using this framework, we illustrate how clinicians could more effectively tailor treatment strategies to individual ESRD patients by combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences.