A comparison of treatment options for management of end stage kidney disease in elderly patients: a systematic review

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Abstract

Background

Chronic kidney disease is a global public health problem of increasing prevalence. There are five stages of kidney disease, with Stage 5 indicating end stage kidney disease (ESKD) requiring dialysis or death will eventually occur. Over the last two decades there have been increasing numbers of people commencing dialysis. A majority of this increase has occurred in the population of people who are 65 years and over. With the older population it is difficult to determine at times whether dialysis will provide any benefit over non-dialysis management. The poor prognosis for the population over 65 years raises issues around management of ESKD in this population. It is therefore important to review any research that has been undertaken in this area which compares outcomes of the older ESKD population who have commenced dialysis with those who have received non-dialysis management.

Objective

The primary objective was to assess the effect of dialysis compared with non-dialysis management for the population of 65 years and over with ESKD.

Inclusion criteria

Types of participants

Inclusion criteria

This review considered studies that included participants who were 65 years and older. These participants needed to have been diagnosed with ESKD for greater than three months and also be either receiving renal replacement therapy (RRT) (hemodialysis [HD] or peritoneal dialysis [PD]) or non-dialysis management. The settings for the studies included the home, self-care centre, satellite centre, hospital, hospice or nursing home.

Types of intervention(s)/phenomena of interest

This review considered studies where the intervention was RRT (HD or PD) for the participants with ESKD. There was no restriction on frequency of RRT or length of time the participant received RRT. The comparator was participants who were not undergoing RRT.

Types of studies

This review considered both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies.

Types of studies

This review also considered descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.

Types of outcomes

This review included any of the following primary and secondary outcome measures:

Search strategy

The search strategy aimed to find both published and unpublished studies up to November 2012. A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL were undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference lists of all full text articles reviewed were searched for additional studies. There was no restriction by date range and only studies published in English were considered.

Methodological quality

Two reviewers and an associate reviewer assessed the papers selected for retrieval independently. The reviewers who undertook this review used a standardized appraisal instrument. The reviewers assessed the papers for methodological quality prior to inclusion in the review. In the assessment process a standardized appraisal instrument was used, the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix IV).

Data collection/extraction

Quantitative data were extracted from the included papers using the standardized data extraction tool from JBI-MAStARI (Appendix VI). Details regarding the type of participants, the comparison between dialysis and non-dialysis management, the number of participants and the outcomes (e.g. quality of life, comorbidities, survival, hospital admissions, functional capacity and symptoms) were extracted.

Data synthesis

Meta-analysis of the data was not possible so the authors have undertaken a narrative summary of the results from the included studies.

Results

Of the 24 articles that were retrieved in full, 20 articles were excluded as not meeting the inclusion criteria. The remaining four studies were reviewed with a further one article excluded due to poor study design and inadequate comparator population. The final three studies were all observational in design, two being prospective in design and one retrospective. The three studies were not homogenous and differed in the clinical and methodological dimensions. The outcomes measured included survival, impact of factors on survival (these factors included comorbidity, peripheral vascular disease, presence of diabetes, age, functional performance score, modality, late referral and Body Mass Index), rate of hospitalizations and location of death. The only outcome measured in all three studies was survival, with all studies demonstrating improved survival in the intervention group. Survival was compromised by the presence of comorbidity (ischaemic heart disease) and lowered functional performance. One study found the rate of hospitalizations was higher in the intervention group and also the location of death for the intervention group was more likely to be in the hospital.

Conclusions

It is difficult to translate the outcomes summarized in this systematic review into recommendations for practice as only three studies met the inclusion criteria and within these studies there was a lack of homogeneity in study design, potential confounders and also a high risk for bias. In consideration of these limitations, all three studies showed a survival advantage for the intervention group; however this advantage was lost in the presence of severe comorbidities, in particular, ischaemic heart disease. In addition, if an individual had very poor functional performance, survival would be substantially reduced. It is important to continue to expand the evidence on whether to commence RRT for people who are older, particularly those aged greater than 75 years. Further studies should also include measuring quality of life and symptom severity in addition to survival outcomes.

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