Blogs to Boards: Question 17

Mr G is a 74-year-old nursing home resident with coronary artery disease and end-stage renal failure (eGFR of 12). He is considering starting treatment with dialysis but would like to know more about what life will be like after starting dialysis.

What would be the most accurate statement in regards to his prognosis?

  1. His functional status is likely to improve with renal replacement therapy 
  2. His functional status is likely to be maintained at his pre-dialysis level 
  3. He is unlikely to have significant symptom burden if he elects not to initiate dialysis 
  4. The majority of nursing home residents die within one year of starting dialysis

Discussion:  Correct answer is (d)

  1. Based on a NEJM paper (1) that linked dialysis registry data to activities of daily living measures reported by nursing homes in 3,702 patients, patients similar to Mr. G did poorly. Within 3 months after the start of dialysis, 61% of the nursing home residents had died or had a decrease in functional status as compared with their functional status before dialysis. Only 39% had the same functional status that they had before dialysis. By 12 months, almost all (87%) nursing home residents had died or had a decrease in functional status after starting dialysis.
  2. See a above
  3. The last month of life for individuals who elect not to undergo renal replacement therapy is associated with relatively high symptom burden, similar to that of advanced cancer.(2) Common symptoms include lack of energy, itching, feeling drowsy, shortness of breath, difficulty concentrating, pain, lack of appetite, and swelling of arms/legs. Therefore, clinicians should attend to these symptoms as aggressively as they do for patients with advanced cancer. We don’t know though whether symptom burden is improve or worsened for elderly patients with multiple chronic conditions who do elect for renal replacement therapy.
  4. In the NEJM cited above, 58% of these nursing home residents had died 1 year after initiating dialysis.

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