Monday, March 2, 2015

The intersection of nephrology and palliative care

by Joel Topf, MD

Have you ever read a journal article and as soon as you finished the abstract you had this forbidding feeling that if the authors actually proved what they claimed to have discovered your medical life will never be the same?

This happened to me when I read, “Functional Status of Elderly Adults before and after Initiation of Dialysis (OPEN ACCESS)” by Tamura et al. in 2009.

This study simply looked at the mortality and functional status of nursing home residents who initiated dialysis. The cohort consisted of 3,704 Americans. The average age of this predominantly white (64%) female (60%) cohort was 74 years. The outcomes were horrifying:
  • Within three months of starting dialysis 61% had died or had a decrease in their functional status
  • By one year that figure was 87%
  • By one year only 1 in 8 patients had maintained their functional status from before dialysis
While this study did not track patients who deferred dialysis it is hard to imagine they could do much worse. The view of dialysis as a way to improve functional status by clearing uremia leading to improved nutrition and other downstream benefits was revealed to be a false hope. Instead we have a treatment that appears to be too rough for frail, at-risk patients and left them significantly worse than they were before dialysis.

The discussion section of the article had a sentence that should be embroidered to every nephrologists white coat:
“...kidney failure may be a reflection of terminal multiorgan dysfunction rather than a primary cause of functional decline, and thus the initiation of dialysis may not rescue patients from an inevitable decline.”
As nephrologists we need to elevate conservative, non-dialytic, therapy to be a clear option for patients, one that should be discussed along with peritoneal dialysis and transplant. Conservative care should not merely be a last resort when all other options have been exhausted.

I hope you will join us as we discuss the intersection of nephrology and palliative care this Wednesday at #hpm chat.

Dr. Joel Topf is a nephorologist who writes at Precious Body Fluids and is a leading social media ambassador in nephrology circles. You can find him on Twitter @kidney_boy

What: #hpm chat on Twitter
When: Wed 3/4/2015 - 9p ET/ 6p PT
Host: Joel Topf 
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