What are the recommended guidelines for managing the aging dialysis patient?

Managing the Aging Dialysis Patient

I cannot provide specific Philippine Society of Nephrology guidelines for aging dialysis patients as none were included in the evidence provided. However, I can offer evidence-based recommendations from international nephrology guidelines that address this population.

Key Principles for Aging Dialysis Patients

The most critical decision for aging dialysis patients is determining whether dialysis initiation or continuation provides meaningful survival or quality-of-life benefit, particularly for those aged ≥75 years with multiple comorbidities, frailty, or functional impairment. 1

Patient Selection and Shared Decision-Making

• Implement systematic screening using the "Surprise Question" ("Would I be surprised if this patient died in the next year?") to identify seriously ill patients who may not benefit from dialysis 1

• Explicitly offer comprehensive conservative care as a viable alternative to dialysis for patients aged ≥75 years with ≥2 of the following: multiple comorbidities, frailty, functional impairment, cognitive impairment, or a "no" response to the Surprise Question 1

• Evidence suggests survival advantage of dialysis disappears in patients over 75 years with high comorbidity levels and/or poor functional status 1

• Ensure fully informed consent by discussing all treatment options including: available dialysis modalities, comprehensive conservative care with end-of-life planning, time-limited trial of dialysis, and stopping dialysis with palliative care 1

Dialysis Prescription Modifications

Blood Pressure Management:

• Target systolic BP <130 mmHg may be reasonable for many older dialysis patients, but management must account for tolerance to BP lowering and risk of syncope, hypotension, and electrolyte abnormalities 1
• Exclude patients with standing SBP <110 mmHg from intensive BP targets due to increased adverse event risk 1
• Use stepped-care approach rather than starting with 2-drug therapy when initiating BP medications in elderly patients with SBP ≥150 mmHg 1

Glycemic Control:

• Target hemoglobin A1C of approximately 7% in dialysis patients, recognizing that A1C may underrepresent glycemic control due to anemia and shortened red cell lifespan 1
• Exercise caution to prevent hypoglycemic episodes, particularly in patients with nausea or gastrointestinal complaints 1

Dialysis Adequacy:

• Avoid initiating dialysis at higher GFR levels, as earlier dialysis initiation does not improve survival and leads to greater resource utilization without clinical benefit 1

Comprehensive Conservative Care Components

When conservative care is chosen or medically advised, provide:

• Multiprofessional team delivery including nephrologist, nurse, psychosocial worker, dietician, and integration with specialist palliative care 1

• Systematic symptom assessment using validated tools (ESAS-R, iPOS-R) to identify and manage troublesome symptoms including confusion, sleep disturbances, fatigue, and pain 1, 2

• Dietary management with controlled phosphate intake through dietary modifications and phosphate binders, appropriate protein intake to prevent malnutrition while minimizing uremic waste 2

• Pharmacological support including loop diuretics and sodium polystyrene sulfonate for volume and electrolyte management 2

• Advance care planning with documented discussions, completion of advance directives, and medical orders (DNR, POLST) to ensure patients' wishes are known and respected 1

Prognostic Discussions

• Conduct early and ongoing discussions about life expectancy and quality of life with patients or legal agents, documenting these conversations 1

• Reassess treatment goals when patients encounter major complications that substantially reduce survival or quality of life 1

• Recognize that hospitalization rates are reduced and home death rates increased for patients receiving comprehensive conservative care 1

Home Dialysis Considerations

• Home dialysis (peritoneal dialysis or home hemodialysis) can be feasible for older adults but requires careful assessment of physical limitations, cognitive function, caregiver availability, and risk of treatment-related complications 3, 4

• Assisted peritoneal dialysis makes this modality more accessible for older patients with functional limitations 3

Common Pitfalls

• Avoid one-size-fits-all approaches - seriously ill patients constitute 20% of the dialysis population with different prognosis and needs requiring focused supportive care aligned with their values 1

• Do not focus solely on laboratory values when determining treatment intensity; consider the whole patient including symptoms, functional status, and quality of life 2

• Recognize that intensive dialysis targets (more frequent or longer sessions) have not demonstrated survival benefit in standard three-times-weekly dialysis and may increase treatment burden 1

• Monitor closely for adverse effects from BP lowering, especially acute kidney injury, which is the most common adverse effect with intensive BP targets 1

Conflict Resolution

• Implement systematic conflict resolution processes when disagreement exists between patient/legal agent and the renal care team regarding dialysis benefits 1

• Consider time-limited trials of dialysis for patients with uncertain prognosis or when consensus cannot be reached 1, 2