Abstract
Age is commonly used as guidance in a variety of life activities having extensive influence on people's lives from social to legal aspects. Health care is no exception, where treatment is often subliminally declined as a certain age is reached, mainly for economic reasons. Humans age at different and unpredicted rates, related to the development of co-morbid conditions, most notably diabetes and cardio-vascular pathology. The way we think about age and being old greatly affects how we will choose between the treatment options. Instead, if we consider the disease or diagnosis as the treatment guide, age will be cancelled out, and become a covariant in addition to all other contributing factors in a specific patient's disease state. This thinking would help the planning and likely improve the selection of renal replacement therapy in patients with kidney failure, where therapeutic options range from no treatment to renal transplant, based on clinical conditions considering risk and outcome projections, regardless of age.
We have read with great appreciation the accurate, balanced opinion of Masengu et al published in this issue of the Journal of Vascular Access regarding optimal outcomes in the elderly with end-stage renal disease (1). The paper has been well researched and well referenced and it stands on solid ground. And yet, on another level it opens up pathways for much needed conversation about age, ageism and the power of words in framing these discussions. There is value in redirecting the discussion for a moment to consider the subject matter through a semantic filter; after all, words are powerful. The words we use affect our way of thinking and ultimately patient care.
There is much health-care debate about the care for the elderly, such as the use of hospice as a dignified end-of-life solution. These discussions are grounded in humanist ethics, but frequently dovetail into questions about money and who is going to pay for costly care. The questions are tedious, draining and without easy answers. There is a deep, encompassing implication that aging means deterioration; to age is a path downward towards eventual demise. To age is human, a part of the life cycle and of course, inevitable. However, age and the aging process are neither specific nor uniform in their manifestation.
In the kidney transplant setting, age itself is not considered a specific contraindication to transplantation. It used to be. The number of comorbidities and the impaired functional status are the crucial elements taken into consideration when deciding to include patients in the transplant list. Older age is just a state where these elements are more common, but not necessarily present. In accordance with this line of reasoning, Masengu et al (1) point out that in the French REIN study (2), exploring 6-month survival in elderly patients who are starting dialysis therapy, age was not an independent risk factor for mortality.
On the other side of the coin, it is also worth noting that age and patient status are not mutually exclusive. Consider this hypothetical pair in the chronic kidney disease area: a 35-year-old patient with type 1 diabetes on dialysis with blindness, several amputations, coronary artery disease, on a catheter versus a 75-year-old patient on peritoneal dialysis without co-morbidity (except age!). Who is better off?
We suggest a semantic paradigm shift. Instead of utilizing the laden word ‘age,’ let us address co-morbidity as the main subject line. Then, age becomes one of the many co-variants. This simple change of words will cancel out age and all of its attendant implications and re-focus the thinking towards the actual causes of kidney disease to focus on the best treatment options. We would favor the article addressing co-morbidity as the primary issue, in which case age is likely to be a significant contributing factor.
Second, like most publications in this field, our Belfast colleagues point out the benefits with native vein access over graft and catheters. Phrases and words like ‘gold standard, preferred, proven superior, should be tried first, CMS mandated’ are utilized to frame and shape a particular line of thinking (3). The fistula first concept was built on data, where early failures were excluded. Yes, native veins do better when they mature in patients who have the suitable anatomy. Grafts do better than native veins in co-morbid patients with no useable veins. A catheter may be the most humane in end-of-life situations regardless of age. This is the better way of thinking about dialysis access (4, 5). Older age should not preclude AV fistula creation (6––8) and grafts can be a better option when vessels are not adequate for AV fistulae (9). We should seek to place the best access for each patient every time based on the teams’ knowledge and skill set (including the surgeon), co-morbidity, physical examination, ultrasound mapping, surgical anatomy, without using age as an independent covariant. With this approach (external) pressures or mandates to place or favor a certain access is eliminated.
Just do the right thing! The right thing to do for your fellow human is to use your skills and knowledge and available resources modelled by the culture and beliefs in the society where you live and work. Literature supports this view (10, 11). Patients’ perspectives should also be greatly taken into consideration (12), adopting an individualized approach that seeks to achieve the best outcomes (1), regardless of age.
In conclusion, we are bringing to readers of the Journal of Vascular Access a different way of thinking about age and the selection process of access to dialysis in the end-stage renal disease comorbid population. We hope this will spark a discussion on the issue of age as a determinant of dialysis access selection and outcome.
Footnotes
Financial support: No financial support.
Conflict of interest: No conflict of interest.