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Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study
Abstract
Background Evidence-based health policy is urgently needed to meet the increasing demand for health services among elderly people, particularly for expensive technologies such as renal-replacement therapy. Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. We undertook a comprehensive assessment of outcomes in patients 70 years or over.Methods We did a 12-month prospective cohort study of outcomes in 221 patients with end-stage renal failure aged 70 years or over recruited from four hospital-based renal units. We assessed 1-year survival in 125 incident patients (70-86 years) and disease burden (hospital admissions, quality of life, costs) in 174 prevalent patients (70-93 years).Findings 1-year survival rates were: 71% overall; 80%, 69%, and 54% in patients 70-74 years, 75-79 years, and 80 years and older, respectively (p=0.008); and 88%, 71%, and 64% in patients with no, one, or two or more comorbid conditions, respectively (p=0.056). Cox regression analyses showed that mortality was significantly associated with age 80 years and older (relative risk 2.79 [95% CI 1.28-6.93]) and peripheral vascular disease (2.83 [1.29-6.17]), but not with diabetes, ischaemic heart disease, cerebrovascular disease, chronic obstructive airways disease, sex, or treatment method. In terms of disease burden, hospital admissions represent a low proportion of costs and was not required by a third of patients, mental quality of life in elderly dialysis patients was similar to that of elderly people in the general population, and the average annual cost per patient of 20802 (US$31200) (68% dialysis treatment, 1% transport, 19% inpatient hospital admissions, 12% medications) was within the range of other life-extending interventions.Interpretation Our results suggest that age alone should not be used as a barrier to referral and treatment and emphasise the need to consider the benefits of dialysis in elderly people. Indicators of the ability to benefit from treatment, rather than chronological age, should be used to develop policies that ensure equal access to care for all.
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“Similar findings have been noted in community-dwelling elderly patients [20].”
From Should there be an expanded role for palliative care in end-stage renal disease? (2010) · cites this paper as [20]
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“This paradigm arises from a number of factors, including a general awareness among nephrologists of observational data that suggest equivalent outcomes for, firstly, peritoneal dialysis versus hemodialysis (Jager et al., 2001; Lamping et al., 2000, Vonesh & Moran, 1999), and secondly, generally better outcomes for hom…”
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“In addition, in elderly patients (those over the age of 70) with end-stage renal disease on dialysis, 46% were found to have PAD [56].”
BackgroundRelação do sexo e da idade com nível de qualidade de vida em renais crônicos hemodialisados
Santos, P. R. (2006) · Revista da Associação Médica Brasileira · doi:10.1590/s0104-42302006000500026 · Cited by 48
Thompson, S., Gill, J., Wang, X., Padwal, R. S., Pelletier, R., Bello, A. K., Klarenbach, S. W., & Tonelli, M. A. (2012) · Kidney International · doi:10.1038/ki.2012.167 · Cited by 54
“In a smaller study from England, the risk of mortality was higher for incident dialysis patients over 80 years of age; however, comorbidity was a more significant predictor of outcome than age.(9) Future studies should collect detailed information on clinical characteristics such as the severity of comorbid conditions…”
BackgroundClassifying kidney problems: can we avoid framing risks as diseases?
Clase, C. M., Garg, A. X., & KIBERD, B. A. (2004) · BMJ · doi:10.1136/bmj.329.7471.912 · Cited by 52
Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5
Reindl‐Schwaighofer, R., Kainz, A., Kammer, M., Dumfarth, A., & Oberbauer, R. W. (2017) · PLoS ONE · doi:10.1371/journal.pone.0181345 · Cited by 55
Assisted peritoneal dialysis as a method of choice for elderly with end-stage renal disease
Dimkovic, N. B., & Oreopoulos, D. G. (2008) · International Urology and Nephrology · doi:10.1007/s11255-008-9427-7 · Cited by 52
Berger, J. R., Jaikaransingh, V., & Hedayati, S. S. (2015) · Advances in Chronic Kidney Disease · doi:10.1053/j.ackd.2015.08.005 · Cited by 55
Cost of renal replacement: how to help as many as possible while keeping expenses reasonable?
Vanholder, R. C., Lameire, N. H., Annemans, L., & Biesen, W. V. (2015) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfv233 · Cited by 52
“However, these drawbacks do not prevail if comorbidities are absent [49, 106, 107].”
BackgroundRen, Q., Shi, Q., Ma, T., Wang, J., Li, Q., & Li, X. (2019) · Health and Quality of Life Outcomes · doi:10.1186/s12955-019-1146-5 · Cited by 51
“On dialysis initiation, the elderly have increased morbidity and mortality, along with a variety of post-dialysis symptoms and comorbidities, such as disequilibrium syndrome [10].”
BackgroundShih, C.-J., Chen, Y., Ou, S., Yang, W., Kuo, S., & Tarng, D. (2014) · BMC Medicine · doi:10.1186/s12916-014-0169-3 · Cited by 51
“Some authors have argued that older patients may have no real choice in dialysis decision making due to the lack of comprehensive insurance coverage, which may prohibit access to dialysis through implicit or explicit dialysis rationing due to limited medical resources and financial barriers [27-29].”
BackgroundFactors Predicting Mortality in Elderly Patients on Dialysis
Verdalles, Ú., Abad, S., Aragoncillo, I., Villaverde, M., Jofre, R., Verde, E., Vega, A., & López‐Gómez, J. M. (2010) · Nephron Clinical Practice · doi:10.1159/000286347 · Cited by 48
“Our own results support this notion; since the factor found to be independently related to mortality was incident comorbidity as measured with the Charlson index. Thus, in elderly patients with important comorbidity, it must be taken into account that the treatment of advanced chronic kidney disease with RRT in most c…”
ResultDialysis and the Elderly: An Underestimated Problem
Buemi, M., Lacquaniti, A., Bolignano, D., Donato, V., Fazio, M. R., Campo, S., Coppolino, G., & Sturiale, A. (2008) · Kidney & Blood Pressure Research · doi:10.1159/000164277 · Cited by 45
“The nutritional parameters, including albumin, prealbumin and body mass index (BMI), are of great importance in establishing the elderly patient’s prognosis: the course of dialysis is greatly influenced by the number of co-morbidities present at its initiation, and their severity. The age factor is of evident prognost…”
BackgroundNon-Contact Vital Sign Monitoring in the Clinic
Villarroel, M., Jorge, J., Pugh, C. W., & Tarassenko, L. (2017) · International Conference on Automatic Face and Gesture Recognition · doi:10.1109/fg.2017.43 · Cited by 46
“In dialysis studies, the patient population is usually comprised of elderly patients [11], [12], hence the average age for a patient in this study was 64.”
BackgroundRenal function and renal disease in the elderly:
Mulder, W. J., & Hillen, H. F. P. (2001) · European Journal of Internal Medicine · doi:10.1016/s0953-6205(01)00121-2 · Cited by 45
Dialysis Options for End-Stage Renal Disease in Older People
Brown, E. A., & Johansson, L. (2011) · Nephron Clinical Practice · doi:10.1159/000328019 · Cited by 43
Self-citationStringer, S. J., & Baharani, J. (2011) · International Urology and Nephrology · doi:10.1007/s11255-011-0045-4 · Cited by 43
“Survival advantage of patients over 75 on dialysis is negligible when those individuals have significant co-morbidity, especially ischaemic heart disease [ 3 , 6, 9].”
BackgroundCosts of dialysis for elderly people in the UK
Grun, R. P. (2003) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfg354 · Cited by 41
“The cost evaluation was conducted as part of the North Thames Dialysis Study (NTDS), a prospective cohort study to evaluate clinical outcomes, quality of life (QOL) and costs in dialysis patients aged 70 years or over [7].”
BackgroundMethodResultInfluentialChronic kidney disease and the aging population
Tonelli, M. A., & RIELLA, M. C. (2014) · Brazilian Journal of Nephrology · doi:10.5935/0101-2800.20140001 · Cited by 41
A Patient‐Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First
Kalloo, S. D., Blake, P. G., & Wish, J. B. (2016) · Seminars in Dialysis · doi:10.1111/sdi.12465 · Cited by 41
Quality of life in the elderly patients on dialysis
Apostolou, T. (2007) · International Urology and Nephrology · doi:10.1007/s11255-007-9225-7 · Cited by 41
Yang, X., Fang, W., Kothari, J., Khandelwal, M., Naimark, D. M. J., Jassal, S. V., Bargman, J. M., & Oreopoulos, D. G. (2007) · International Urology and Nephrology · doi:10.1007/s11255-007-9279-6 · Cited by 40
“Among elderly patients older than 65 years, 30% had three or more additional diagnoses [12].”
BackgroundHigh Cost and Low Survival Rate in High Comorbidity Incident Elderly Hemodialysis Patients
Lin, Y., Wu, P., Kuo, M., Lin, M., Lee, T.-C., Chiu, Y., Hwang, S., & Chen, H. (2013) · PLoS ONE · doi:10.1371/journal.pone.0075318 · Cited by 40
“In the North Thames Dialysis Study in the UK, the one-year survival for dialysis patients over 70 years of age was 71% [26].”
BackgroundSPANISH NEPHROLOGY NURSES’ VIEWS AND ATTITUDES TOWARDS CARING FOR DYING PATIENTS
Ho, T. M., Barbero, E., Hidalgo, C., & Camps, C. (2010) · Journal of Renal Care · doi:10.1111/j.1755-6686.2010.00141.x · Cited by 40
“Some of them therefore may not be suitable for dialysis at all, some may choose to withdraw from treatment after a period of time or some may reach the end of their lives while still on dialysis (Lamping et al. 2000; Smith et al. 2003; Germain et al. 2007).”
BackgroundPriority dilemmas in dialysis: the impact of old age
Halvorsen, K., Slettebø, Å., Nortvedt, P., Pedersen, R., Kirkevold, M., Nordhaug, M., & Brinchmann, B. S. (2008) · Journal of Medical Ethics · doi:10.1136/jme.2007.022061 · Cited by 38
Automated Peritoneal Dialysis Symposium: APD in the Elderly
Kadambi, P. V., Troidle, L. K., Gorban‐Brennan, N., Kliger, A. S., & Finkelstein, F. O. (2002) · Seminars in Dialysis · doi:10.1046/j.1525-139x.2002.00106.x · Cited by 37
“In fact, a prospective, cohort study comparing CPD and hemodialysis (HD) for elderly patients with ESRD found very similar results with both modalities (7).”
BackgroundResultInfluentialEpidemiology of end-stage renal disease
Roderick, P. J. (2002) · Clinical Medicine · doi:10.7861/clinmedicine.2-3-200 · Cited by 37
Self-citationSurveillance de la qualité de vie des sujets atteints d’insuffisance rénale chronique terminale
Boini, S., Bloch, J., & Briançon, S. (2009) · Néphrologie & Thérapeutique · doi:10.1016/s1769-7255(09)74545-6 · Cited by 37
“La comparaison avec des témoins montre que la qualité de vie des insuffisants rénaux est altérée, notamment dans sa composante physique et générale, contrairement à la composante mentale [2-6].”
BackgroundConservative management for patients with chronic kidney disease refusing dialysis
Castro, M. C. M. (2018) · Brazilian Journal of Nephrology · doi:10.1590/2175-8239-jbn-2018-0028 · Cited by 47
Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review
Chou, A., Li, K. C., & Brown, M. A. (2022) · Kidney Medicine · doi:10.1016/j.xkme.2022.100447 · Cited by 38
“7 45 30-63 Comparison of CKM and Peritoneal dialysis patients Brown35 Decision date 16 (7-39) 53 93 33a 95% CI, 32-34 Kwok27 eGFR <15 mL/ min/1.”
MethodChronic Peritoneal Dialysis in the Elderly
Dimkovic, N. B., & Oreopoulos, D. G. (2002) · Seminars in Dialysis · doi:10.1046/j.1525-139x.2002.00038.x · Cited by 36
Caring for critically ill oldest old patients: a clinical review
Vargas, N., Tibullo, L., Landi, E., Carifi, G., Pirone, A., Pippo, A., Alviggi, I., Tizzano, R., Salsano, E., Grezia, F. D., et al. (2016) · Aging Clinical and Experimental Research · doi:10.1007/s40520-016-0638-y · Cited by 37
“[95] found that 12-month survival rate of elderly patients on dialysis was lower in patients aged over 80 years (54 %) versus patients aged between 75 and 79 years (69 %) and versus patients aged between 70 and 74 years (80 %).”
BackgroundShould Older Patients be Offered Peritoneal Dialysis?
Brown, E. A. (2008) · Peritoneal Dialysis International · doi:10.1177/089686080802800503 · Cited by 35
“Quality of life was measured in the NTDS (12) using the SF-36 and Kidney Disease Quality of Life Questionnaire (KDQOL).”
BackgroundMethodInfluentialSelf-citation
Metadata
- Authors
- Lamping, D. L., Constantinovici, N., Roderick, P., Normand, C., Henderson, L., Harris, S., Brown, E., Gruen, R., & Victor, C.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- The Royal Free Hospital (GB)
- University of Southampton (GB)
- Charing Cross Hospital (GB)
- St George's Hospital (GB)
- Corresponding author
- Lamping, Donna L
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2000-11
- Volume
- 356
- Issue
- 9241
- Pages
- 1543-1550
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2122886742
- Cited by
- 349
- References
- 27
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 3 · 2023: 6 · 2022: 7 · 2021: 4 · 2020: 8 · 2019: 7 · 2018: 12 · 2017: 8 · 2016: 20 · 2015: 16 · 2014: 32 · 2013: 32 · 2012: 24
- FWCI
- 5.96
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
- Keywords
- elderly dialysis patients, end-stage renal disease, renal replacement therapy, survival, comorbidities, peripheral vascular disease, quality of life, hospitalization, health care costs, health policy, elderly health services, cost-effectiveness
- MeSH terms
- Aged, Aged, 80 and over, Female, Health Services for the Aged, Renal Dialysis, Hospitalization, Humans, Kidney Failure, Chronic, London, Male, Prospective Studies, Quality of Life, Social Class, Health Care Rationing, Comorbidity, Survival Rate, Multivariate Analysis, Treatment Outcome, Resource Allocation
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