Understanding the Reality of End-Stage Renal Disease (ESRD) in the Elderly
For many seniors, a diagnosis of End-Stage Renal Disease (ESRD) forces a difficult conversation about treatment options. While dialysis is the standard path for many, it is not always the right choice for elderly individuals, especially those with multiple other health conditions. The process of dialysis can be physically taxing and may not significantly improve quality of life, or even extend life, for a frail 85-year-old. This makes understanding the alternatives, particularly supportive care without dialysis, critically important.
The Variability in Prognosis
It's important to state upfront that there is no single answer to how long an 85-year-old can live without dialysis. The prognosis is highly individual. While some may live only days to a few weeks as toxins build up in the body, others may live for many months. Recent research has shed light on these variations, revealing important considerations for patients and families.
A 2015 study published in the Clinical Journal of the American Society of Nephrology found that elderly patients managed with renal supportive care, without dialysis, had a median survival of 16 months. A significant finding was that about one-third of these patients survived for more than 12 months after their kidney function dropped to a level where dialysis would normally be considered. This highlights that forgoing dialysis does not necessarily mean an immediate decline but rather a shift in focus from curative treatment to comfort and quality of life.
Key Factors That Influence Survival
Several factors play a significant role in determining the life expectancy of an elderly patient with kidney failure who forgoes dialysis. These include:
- Comorbidities: The presence of other serious health conditions, such as heart disease, diabetes, or vascular disease, is a major predictor of poorer survival. Frailty, cognitive impairment, and a lower level of daily activity also worsen the prognosis. In fact, for very elderly patients with multiple comorbidities, the survival benefit of dialysis over supportive care may be minimal.
- Remaining Kidney Function: The individual's remaining glomerular filtration rate (eGFR) at the time of the decision is critical. The faster the kidney function declines, the shorter the expected survival. As the eGFR falls below 15 mL/min, the risk of death increases, but effective palliative care can manage symptoms to maintain comfort.
- Nutritional Status: Malnutrition is common in advanced kidney disease and is linked to poorer outcomes. Maintaining adequate nutrition through dietary support is a key component of conservative management.
- Fluid and Toxin Management: Without dialysis, the body's ability to regulate fluid and excrete toxins is severely compromised. How effectively these symptoms are managed through medication and dietary adjustments will impact both quality of life and longevity.
The Conservative Management Approach
When the decision is made to not pursue or to stop dialysis, the patient transitions to conservative kidney management, also known as renal supportive care or palliative care. This approach focuses on managing symptoms and enhancing the patient's quality of life rather than prolonging it through intensive medical interventions. A multidisciplinary team, including nephrologists, palliative care specialists, and social workers, is involved in this process.
Common supportive care interventions include:
- Medication management for symptoms like nausea, itching, pain, and sleep disturbances.
- Dietary adjustments to help control potassium, phosphorus, and fluid balance.
- Emotional and spiritual support for the patient and family.
- Coordination of hospice services when appropriate.
Comparing Dialysis and Supportive Care
Making a choice between dialysis and conservative management is complex, especially for an elderly individual. The following table provides a high-level comparison based on outcomes observed in studies involving older adults.
| Feature | Dialysis (Hemodialysis) | Conservative Management (No Dialysis) |
|---|---|---|
| Life Expectancy | May offer a moderate survival advantage, particularly for healthier elderly patients. Median survival for octogenarians may be less than 16 months even with dialysis. | Variable, often ranging from months to over a year. Median survival can be around 16 months for older patients receiving supportive care. |
| Quality of Life | Can be burdensome, with regular trips to a clinic and significant time commitment. Studies suggest some older patients on dialysis may spend more time hospitalized or in facilities. | Focused on comfort and symptom control. Can mean more time at home and fewer invasive procedures, potentially leading to better quality of life. |
| Symptom Burden | Can effectively manage uremic symptoms, but may introduce new ones (e.g., cramping, fatigue) associated with the treatment. | Symptoms are managed with medications. The overall goal is to relieve suffering as the disease progresses. |
| Focus of Care | Curative and life-prolonging. | Palliative and quality-of-life focused. |
The End-of-Life Experience
For a patient who chooses to live without dialysis, the final weeks and days are managed through palliative and hospice care. As kidney function ceases, toxins build up, leading to a progression of predictable symptoms.
Common end-of-life signs include:
- Mental Status Changes: Growing confusion, delirium, and increased sleepiness are common as uremia progresses.
- Decreased Appetite and Fluid Intake: The body's need for food and water diminishes significantly. Forcing nourishment is not recommended.
- Fluid Overload: Edema (swelling) in the feet and hands is common, and fluid can build up in the lungs, causing shortness of breath.
- Breathing Changes: As death nears, breathing may become shallow, irregular, or labored.
- Physical Changes: A person may become unresponsive, and their skin may cool and change color as circulation diminishes.
Comfort care includes medications to ease symptoms and ensure the patient is not in pain. The focus is on providing peace and dignity during the final stage of life, allowing the patient to remain comfortable at home if possible. For resources on making these difficult choices, a guide on renal supportive care is available at https://www.kidney.org/kidney-topics/how-does-palliative-care-improve-quality-life-kidney-patients.
Conclusion
While a definitive timeline is impossible, research suggests that for an 85-year-old with kidney failure, life expectancy without dialysis is often measured in months, though it can vary from weeks to over a year. The decision to pursue conservative, supportive care is a valid and often preferred option for many elderly patients, prioritizing quality of life over potentially limited and burdensome life extension. Open communication with a medical team and a focus on palliative care can ensure dignity and comfort for both the patient and their loved ones during this challenging time.
