I admit I’m drawn to articles in the medical literature that question conventional practices, especially expensive ones. But the implications of a recent editorial in JAMA were even more profound than most.
I won’t repeat the entire article here, but these were some of the most important points:
- There has been a marked increase in the provision of early dialysis in U.S. elderly, paid for by Medicare of course.
- High expenditure regions of the U.S. have higher rates of dialysis initiation.
- A recent randomized controlled trial found no benefit to early dialysis initiation.
- Compared to nondialytic management, elderly patients who undergo dialysis can expect to spend more of their remaining years in dialysis units or in a hospital and are 2 to 3 times more likely to die in a hospital.
- Poor kidney function in the elderly is often stable over a number of years.
- A common laboratory indication for starting dialysis according to the nephr-ologists “is not supported by the literature.”
Early initiation means basically that dialysis is started based on lab values, not severe or uncontrollable symptoms of slowly developing weak kidney function.
The only part of this article I disagreed with was the following statement: “The decision to initiate dialysis should be a joint decision made by patients and nephrologists, after a full disclosure of the potential harms and benefits of dialysis vs nondialysis management.” Take out “nephrologists” and insert family physicians, and we have a deal. Only after a patient chooses the dialysis route does a nephrologist add value to that patient’s life.
The final sentence of this article was a gem. I give the final word to its author, Dr. Rosansky. “The public perception that pursuit of dialysis is always in patients’ best interest should be replaced by a more realistic view of the ‘sad truth’ about early dialysis initiation in elderly patients.”
And recently the normal for creatinine has gone down and now the labs are putting the GFR on the lab results. Try explaining that to your patients.