Peritoneal Dialysis in Centenarian Patients: No Age Limitation?

Introduction

The dialysis population is ageing due to the ageing of the general population and because the prevalence of chronic kidney disease increases with age. In the UK, the dialysis population aged 65 years or older grew by 29% from 2005 to 2008 compared to only by 16% in those aged 18-65 years (1). In the USA, the highest growth rate was observed in the dialysis patients aged over 85 years (2).

Elderly patients with end-stage renal disease (ESRD) tend to present later for dialysis, have a higher co-morbidity burden, are often frail and malnourished, and frequently have cognitive dysfunction and sensory impairments (3). All these factors may complicate the feasibility of dialysis in elderly ESRD patients, and explain why these patients often don't qualify for kidney transplantation. Most older patients will therefore remain on dialysis treatment for the remainder of their lives, unless they choose conservative ESRD care.

Several studies have shown good quality of life as well as excellent patient and technique survival with peritoneal dialysis (PD) compared to in-center hemodialysis (HD) in elderly ESRD patients (4–6). However, The European Renal Association (ERA) EDTA registry data demonstrated that dialysis patients aged ≥70 years are 56% less likely to receive PD than to receive HD in comparison to patients aged 20-44 years (7). In the UK Renal Registry data, 26.9% of patients starting dialysis who were aged <65 years were on PD in 2009, compared to 14.2% of patients aged 65 years or older (1). This relatively low use of PD in elderly ESRD patients occurs despite the potential benefits of this modality in this particular patient population. For the fit elderly, PD may facilitate traveling and continuation of social life activities, and in frail patients it may avoid hemodynamic instability during HD and make frequent transportation to and from the dialysis unit unnecessary.

Patient results

A 100-year-old male patient with stage 3 chronic kidney disease (creatinine 1.8 mg/dL, modification of diet in renal disease [MDRD] 34 mL/min) as a result of nephrosclerosis and multiple renal cysts, was admitted because of urinary tract infection and deterioration of renal function. His creatinine was 12.4 mg/dL, potassium was 5.48 mmol/L, pH 7.26 and bicarbonate 14.8 mmol/L. Renal ultrasound showed hydronephrosis of the left kidney. He was treated with intravenous fluids and antibiotics, and a nephrostomy catheter was inserted. However, kidney function did not recover and hemodialysis (HD) was started using a central venous catheter. Despite his advanced age, he reported a reasonable quality of life at home without aid of home-care nurses, and his nutritional status was acceptable. After geriatric evaluation, we considered him eligible for peritoneal dialysis (PD), and a PD catheter was implanted by mini-laparotomy. Unfortunately, the catheter dislocated with need for laparoscopic repositioning and fixation. It was our patient's personal preference to perform continuous ambulatory peritoneal dialysis (CAPD) instead of automated peritoneal dialysis (APD) with the assistance of home-care nurses who were trained by PD nurses working in our clinic. Until recently, our 100-year-old patient was doing well on CAPD (three-day dwells of 1.5 L biocompatible solution and one overnight dwell of 1.5 L icodextrin), and there had been no need for hospitalization. Regular visits at our outpatient clinic revealed adequate volume and blood pressure control, potassium, parathyroid hormone (PTH) and hemoglobin levels were within target range, and our patient repeatedly confirmed his satisfaction with PD.

Discussion

We are facing a growing number of elderly patients with ESRD requiring renal replacement therapy (RRT) (2, 8). According to a recent ERA EDTA registry report, the growth of dialysis is largely due to a higher incidence of RRT in patients over 75 years of age (9). The burden of dialysis may be high for geriatric patients, and the effect of dialysis on quality of life, functional status, and life expectancy may differ in the elderly as compared to younger patients. Therefore, there is ongoing discussion about the best treatment options for elderly patients with ESRD in the literature, in which consideration of conservative care plays an increasing role.

Data from France, where the majority of elderly ESRD patients are treated with PD, show that patient survival with PD is comparable to that of in-center HD (10). In the cross-sectional multicenter BOLDE (Broadening Options for Long-Term Dialysis in the Elderly) study, Brown et al recently suggested higher quality of life due to its potentially lower illness intrusion in older patients doing PD as compared to HD (4). Also, peritonitis rate and technique survival in older patients is comparable to that in younger patients (2, 11). Oliver et al showed that over 50% of an elderly population deemed suitable for PD chose PD if appropriate multidisciplinary team support and education was provided (12). Also, PD in elderly patients in a nursing home showed excellent patient and technique survival and a low peritonitis rate with good training of the home nursing staff (13).

Few data are available on the very elderly (>90 years) patients undergoing dialysis (14). Especially in the very elderly and potentially frail population, assisted PD can play an important role in maintaining functionality, e.g. by avoiding the need to travel to and from the dialysis center. Realistically, few of the very elderly and frail patients will be able to perform their own PD. Sometimes family members may help, but usually patients are put on in-center HD if these family members are not available. In recent years, however, various options of assisted PD have emerged resulting in the possibility of performing PD in very elderly and frail ESRD patients in their own homes. The largest experience of assisted PD in elderly patients is available in France with more than 50% of PD patients being over 70 years of age (10). Although the French REIN study showed that adverse events such as hospitalization and death were no different between patients on assisted PD and other dialysis modalities, there are no data available about quality of life or patient outcomes on assisted PD compared to HD. This is being addressed by the Frail and Elderly Patient Outcomes on Dialysis (FEPOD) study which will be reported soon (15).

To optimize treatment quality for these very elderly patients, integrated dialysis care delivered by nephrologists, PD nurses, social workers, dieticians and physiotherapists is of crucial importance (12, 16). Also, non-dialysis renal care is always an important therapeutic option in the management of ESRD in elderly patients (17, 18). If elderly patients are mentally disabled, have significant co-morbidities, are no longer able to ambulate, have a poor overall quality of life, and/or have a progressive untreatable disease, physicians should strongly consider conservative treatment of ESRD patients. Conventional dialysis modalities may modestly increase patient survival, but often this is at the expense of increased hospitalization and a reduced likelihood of dying at home (19). Patients and their families should be very well informed in the pre-dialysis clinics about the option of conservative care.

In conclusion, PD is a feasible option in (very) elderly patients with ESRD, which may promote autonomy and functionality compared to in-center conventional HD. This case reiterates that, with appropriate management and infrastructure, (very) high age is not a contra-indication for PD.