Ageism vs the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients

Abstract

Purpose

Treatment intensity for elderly patients with end-stage renal disease has escalated beyond population growth. Ageism seems to have given way to a powerful imperative to treat patients irrespective of age, prognosis, or functional status. Hemodialysis (HD) is a prime example of this trend. Recent articles have questioned this practice. This paper aims to identify existing pre-synthesized evidence on HD in the very elderly and frame it from the perspective of a clinician who needs to involve their patient in a treatment decision.

Patients and methods

A comprehensive search of several databases from January 2002 to August 2012 was conducted for systematic reviews of clinical and economic outcomes of HD in the elderly. We also contacted experts to identify additional references. We applied the rigorous framework of decisional factors of the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) to evaluate the quality of evidence and strength of recommendations.

Results

We found nine eligible systematic reviews. The quality of the evidence to support the current recommendation of HD initiation for most very elderly patients is very low. There is significant uncertainty in the balance of benefits and risks, patient preference, and whether default HD in this patient population is a wise use of resources.

Conclusion

Following the GRADE framework, recommendation for HD in this population would be weak. This means it should not be considered standard of care and should only be started based on the well-informed patient’s values and preferences. More studies are needed to delineate the true treatment effect and to guide future practice and policy.

Keywords:

• cost
• quality of life
• renal replacement therapy
• resource utilization survival
• symptom burden

Supplementary material

Search strategies by database.

Ovid

Database(s): Embase 1988 to 2012 Week 33, Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to Present, EBM Reviews – Cochrane Database of Systematic Reviews 2005 to July 2012.

Search strategy:

Table

Scopus

1. TITLE-ABS-KEY((renal W/5 dialyses) or (kidney w/5 dialyses) or (blood w/5 dialyses) or (peritoneal w/5 dialyses) or (renal W/5 dialysis) or (kidney w/5 dialysis) or (blood w/5 dialysis) or (peritoneal w/5 dialysis) or hemodialysis or haemodialysis or hemodialyses or haemodialyses or “extracorporeal dialysis” or “extracorporeal dialyses” or “extracorporeal blood cleansing” or hemodialyse or hemorenodialysis or hemorenodialyses or hemotrialysate or Hemodiafiltration) AND PUBYEAR > 2001

2. TITLE-ABS-KEY(elderly or octagenarian* or nonagenarian* or “very old” or “75 year*” or “80 year*” or “90 year*” or “100 year*” or (75 w/1 age) or (80 w/1 age) or (90 w/1 age) or (100 w/1 age) or (75 w/1 aged) or (80 w/1 aged) or (90 w/1 aged) or (100 w/1 aged))

3. TITLE-ABS-KEY(outcome* or economic* or cost or costs or benefit* or harm* or preference* or “quality of life” or survival or “functional status” or morbidity or mortality or satisfaction)

4. and 2 and 3

5. PMID(0*) OR PMID(1*) OR PMID(2*) OR PMID(3*) OR PMID(4*) OR PMID(5*) OR PMID(6*) OR PMID(7*) OR PMID(8*) OR PMID(9*)

6. and not 6

7. DOCTYPE(le) OR DOCTYPE(ed) OR DOCTYPE(bk) OR DOCTYPE(er) OR DOCTYPE(no) OR DOCTYPE(sh)

8. and not 7

9. TITLE-ABS-KEY(systematic* w/3 review*)

10. and 9

Acknowledgments

This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

We thank Gladys Hebl from Mayo Clinic Grant and Publication Support Services for her help in preparing this manuscript for publication.

Disclosure

The authors report no conflicts of interest in this work.