The global burden of advanced chronic kidney disease (CKD) has increased significantly in recent decades
PhD candidate Wouter Verberne would like to determine the benefits of dialysis therapy for the elderly. Under the guidance of LUMC professor Willem Jan Bos, he therefore compared the value of dialysis and so-called conservative treatment in advanced chronic kidney disease. His research is now being used to contribute to nephrological care in elderly patients.
The global burden of advanced chronic kidney disease (CKD) has increased significantly in recent decades. This is due to many factors, including obesity, diabetes, high blood pressure and aging. Currently, older patients between the ages of 70 and 80 are the largest and fastest growing group affected by the disease. Because kidney function greatly declines over time, dialysis may be needed to filter the blood.
Standard dialysis treatment
In this setting, dialysis is now considered the standard of care for elderly patients in countries such as the Netherlands, the United States and the United Kingdom. “But it is an intensive therapy, which may not fit within the care goals of each individual,” notes Wouter Verberne, internist in internal medicine training at the University Medical Center Utrecht (UMC Utrecht). Compared to younger patients, the elderly generally suffer from multiple conditions and are more frail. “This has raised the dilemma underlying my current research: do all elderly patients really benefit from dialysis?”
Meaningful care options
Verberne conducted his study under the supervision of Willem Jan Bos, professor of Kidney Diseases and Outcomes of Care at Leiden University and physician in the Internal Medicine Department of the Leiden University Medical Center (LUMC). As a former student of doctor Willem Kolff – inventor of the artificial kidney – Bos describes Kolff’s effort to understand what meaningful care is for the individual patient: “He always said: ‘You should always discuss the advantages and disadvantages of an intensive care unit together. treatment as dialysis.’ Interestingly, during his research, Verberne found that many patients wanted to know about the different treatment options.”
Conservative alternative
“Conservative treatment – which consists of active treatment of patients with medication, dietary and lifestyle advice – has been suggested as a possible alternative to dialysis. In this treatment trajectory, the main goal is to maintain the individual’s quality of life through adequate symptom control, rather than so much so as to prolong life,” explains Verberne. However, comparative data on the results of both treatments are currently limited. “To determine the value of each treatment, I conducted a retrospective study, enrolling patients 70 years of age or older, with advanced chronic kidney disease, who received care at St. Antonius Hospital between 2004 and 2016 and had explicitly opted for dialysis or conservative treatment.”
The researcher showed that – overall – older patients who chose dialysis lived longer, but the increase in life years for those over 80 or with multiple diseases was not significant. “Meanwhile, the quality of life of both patient groups appeared to be comparable and the therapy burden and costs were significantly lower for patients who chose conservative treatment. Thus, the conservative approach is an appropriate care alternative for the elderly.” Verberne’s study is now being used to contribute to guidelines for nephrology in the Netherlands and Europe.
Shared decision making
Bos emphasizes the importance of sharing the treatment decision-making process in the doctor’s office: “Healthcare providers need to look beyond what is considered beneficial only from a medical point of view and also consider what the individual’s life goals are.” He reiterates that all available options – including conservative treatment – should be discussed openly. “Patients should be made aware that their choice not to undergo dialysis is taken seriously and that it is possible to extend survival and quality of life by controlling symptoms, diet and medication.”
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