Dear Dialysis Daughter
Here is my response … I have set out my parts in bold and italics.
Hi, Dr. Agar, and thank you for taking questions!
My father will be turning 90 years old later this month. He lives at home with my mother, and is quite active, though he does need to nap every afternoon.
He has failing kidneys – his GFR is sitting at 15 , and his nephrologist is recommending peritoneal dialysis. However, Dad evidently has 3 hernias that are located quite distant from each other, so a surgeon that he visited wants to slice him open (NOT laparascopic) to repair these hernias. I think he’s scheduled for mid-August.
[B][I]The first thing I would observe is that the elderly commonly ‘wear’ low eGFRs extremely well - and here I mean very low eGFRs - levels well into and below the range your dad is currently running at 15. We would NOT be commencing dialysis in him at an eGFR of 15. Dialysis at this eGFR level will not only make him no better, but will add complexity and risk to a life currently with neither …
As you observe … he looks otherwise to be healthy and in good shape (he traveled 500 miles for his grandson’s graduation ceremony … and he is. At 90, his mean age-matched peer eGFR is likely no better then 40 and while his is indeed low, he will manage quite nicely to well down below 10 … or further.
The data shows that dialysis actually adds risk and co-morbidity to patients >80 with more than one coexisting co-morbidty - especially if that com-morbidity is cardiac - and that dialysis is not always the right solution in this group … indeed that survival between two matched groups of >80’s (a dialysed group and a non-dialysed group) is bvery similar. The surgery to ready your dad - the repair on not one, not two, but three herniae - as you rightly observe, may indeed be the end of him and if they don’t trouble him too much, I would be leaving them (and him) alone.
So … firstly, (a) I would not be embarking on dialysis and (b) I would not be suggesting un-needed surgery.
The only RCT done in this area was the Australian IDEAL trial which compared starting dialysis early or late … and this was in FAR younger patients than your dad. It compared early start dialysis … note here that the ‘early’ group was at an eGFR of 10-12 … against late start dialysis at an eGFR 5-7 … it showed NO benefit from early start and with even more: a worse outcome from early start. This trial has re-informed the European Best Practice Guidelines towards recommending a late start. I was asked to give a keynote talk on this very topic to the European Winter Dialysis Symposium last November in Madrid and I will enclose the slides from the 1st part of that talk for you to look through …
Whoops … I have just realised that I cant do that here, but Dori may be able to suggest how I make these available to you!
So … I would be suggesting that you leave the poor, well, managing and quite eGFR-safe man alone[/I][/B]
While he looks otherwise to be healthy and in good shape (he traveled 500 miles for his grandson’s graduation ceremony), he has actually had a heart attack in the past, type II diabetes, and prostate issues. He’s on a bunch of heart meds (amlodipine, Benicar, Toprol, Isosorbide, Lasix, and low-dose Simvastatin), pioglitazone for diabetes, finasteride for prostate; paricalcitol, phoslo for end stage renal; warfarin, Ecotrin.
We’re afraid that the surgery is going to kill him, before he ever gets to the dialysis. You know the old saying, “the surgery was a success, but the patient died.”
I had an uncomplicated cholecystectomy a couple of years ago, and had quite a bit of difficulty with recovery. I was in excellent shape before the surgery, and was running 2 miles per day, with a very healthy diet. It took me a good month to feel like I was mostly recovered.
If I’m less than half my father’s age, and was in such good shape before the surgery, and had such difficulty (and it was a laparoscopic procedure), I’m very worried that surgery for my father will be problematic.
While your personal surgery experience does not necessarily translate to a similar experience for your dad, I take your point and certainly would agree that a triple hernia repair would carry significant morbidity and mortality in your 90 year old dad and is not surgery I would be embarking on, simply to ready him for a dialysis that I believe, from what you have told me, is a dialysis he currently neither needs nor would benefit from.
While I do agree with him that nocturnal home dialysis would be the best option for him in many ways, I am worried that the surgery will kill him before he ever gets to dialysis, or will severely impact his quality of life. And with that in mind, I can’t help wondering if hemodialysis might be a better option for him, even though it carries a greater risk of infection and cardiac issues (not to mention the inconvenience).
[B][I]Nocturnal dialysis would be difficult (not impossible) but difficult for him - but again, he doesn’t need dialysis, so it’s a theoretical argument, at best. I don’t think that the risk of infection with HD is worse, but certainly dialysis (of either ilk) would have cardiac risks and complications and, again, he doesn’t need dialysis … indeed, in my view, he sounds like he is a long way from it.
I would probably err on the side of saying that while nocturnal dialysis is the best dialysis option where it is possible, feasible, a 90 year old man would likely struggle with it and may be better in a facility (and I choke saying this as I am an advocate for longer, slower, gentler haemodialysis at home) … that is were he to need dialysis … or were he likely to benefit from dialysis … neither of which are the case here.
Again, the elderly wear low eGFRs well. Very well. Far better than do their younger counterparts. Right down to the 5-7 range. Easily. Without symptoms.
I think all current data (and wisdom) tells us that we should never dialyse to a number! And that includes whether that number is a starting eGFR or a dialysis session-finishing Kt/V. When to start dialysis remains an art, an art that needs to be sensitively and compassionately exercised, whatever the eGFR is, and that computes numbers, yes, but numbers factored to the individual, to the patients clinical status, to symptoms, and to perceived risk vs. benefit. It is an art that must be advised by a raft of co-existing features, the last of which is the eGFR ‘number’ and first of which remains the combination answer to two key questions (1) ‘how is the patient feeling’ and (2) ‘is the patient in front of me in trouble yet’.
Remember, dialysis is no bed of roses either, and in the elderly, a sensitive decision must be made between the benefits of dialysis … which are vanishingly few in the elderly patient … and the rigors of the imposition of schedule, roster, travel, and the true clinical risk of the procedure - be it PD or HD.
From what you have told me, and as answers to my (1) and (2) above, I hear neither (1) ‘awful’ or (2) ‘yes’ coming though as clear triggers to the initiation of dialysis in your dad at this point.
To be honest, I would let him be - as, I think, would all Australian, Canadian, UK and European nephrologists that I know. That is not because of his age, but because of his current good health, and his certain ability (along with his fellow elderly) to well-stand eGFRs without symptoms down to the 5-8 range. Alvin Moss, a highly-regarded US nephrologist, has written much on this in the US, too.
I would leave him to enjoy his current good health.
I would anticipate he has significant time left on his non-dialysis-dependent side.
And … I would let him enjoy his afternoon nap … by the time we reach 90, we have all earned that right, and it is not a signal that he needs dialysis, it is a signal that he likes a nap![/I][/B]
There is one more complication here. He is on simvastin (a statin) because that is routinely prescribed with other cardiac medications after a heart attack. His cholesterol has actually never been a problem–his LDL has always been low, his HDL has always been in the optimal range. I’m wondering if #1) he actually needs to be on it and #2) if it might be complicating things for his kidneys and #3) if it might even have triggered his Type 2 diabetes, which did not appear until a few years after he’d started the statin.
[B][I]No … I don’t think that is likely to be right, though rarely, it is true that statins can lead to a myositis + raised total CK + worsening renal impairment syndrome. However, this is truly uncommon and statistically highly unlikely. Moreover, you’d have known about it as it is commonly quite symptomatic when it does happen … which is hardly ever.
As for the statin triggering his diabetes … NO! … this would not be the case. They simply don’t do that. [/I][/B]
Is it possible that my father might be able to delay or even avoid (remember, he’s 90!) dialysis by weaning off the statin? (I wouldn’t do so without guidance from his physicians–it’s just that all his physicians defer to the cardiologist, who seems to believe that EVERYONE with any cardiac history needs statins. But I would think that in my father’s case, the risk of weaning off his statin might be outweighed by potential benefits.
There is no good evidence to say that weaning him off the statin will save his renal function … but if his lipids have never been abnormal in the 1st place, one could easily ask the question … “why is he taking it”? It may be one more pill he takes that at his years, is adding little or no meaningful advantage. I don’t know all the clinical details here, but you raise a fair question.
How on earth does one weigh the risks and benefits in a situation like this??
Thanks in advance, and I’m sorry I threw so many questions into the one post!