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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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ResultClinical outcomes and mortality in elderly peritoneal dialysis patients
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“The North Thames study on dialysis in elderly patients suggested that age alone should not be a barrier to referral and treatment; the investigators emphasized the need to consider the benefits of dialysis in elderly people (29).”
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“This study reported that a relatively high proportion of elderly patients were being treated with PD and that the outcomes of survival and QOL were not different between PD and HD patients (48).”
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“Neither gender, treatment method nor co-morbidity other than peripheral vascular disease appeared to influence outcome in either the French [15] or North Thames study [10].”
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“Survival rates of elderly patients on PD range between 69 and 89% [21, 22], and although renal impairment may decrease quality of life in the elderly [23], many older patients on PD remain autonomous [22].”
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“Dialysis modality Hemodialysis (HD) 188 (82) 43 (84) 108 (78) Peritoneal dialysis (PD) 41 (18) 8 (16) 31 (22) Access HD Catheter 99 (43) 26 (50) 73 (51) AV fistula 53 (23) 15 (29) 38 (27) Unknown 11 (21) 31 (22) Use of Erythropoiesis stimulating agents (ESA) 156 (67) 35 (67) 96 (68) Statins 132 (56) 32 (62) 81 (57) Pr…”
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“The few studies that have looked at quality of life showed that health related quality of life in the elderly dialysis patients is as good, if not better, as in the younger dialysis patients (6,19,20); modality of dialysis does not matter (21).”
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“Although the North Thames Dialysis Study (4) showed that survival, hospitalization, and quality of life were identical for elderly patients on HD and on PD, the proportion of elderly patients on PD was considerably lower than that of younger patients.”
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“3-fold in patients with peripheral vascular disease.(39) If patients, such as DB, had full disclosure to the risks and decrements in quality of life with dialysis initiation, other treatment plans including conservative management may become a more frequent occurrence.”
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“Adjusted estimate of outcome showed a positive PD QoL at 6 months in incident PD patients, compared to their HD counterparts [15].”
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“But it is known that patients with severe comorbidities may not always benefit from dialysis [14,15,18].”
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“Relatively poor functional status and outcomes have been reported for elderly haemodialysis patients, especially in negatively selected cohorts [7, 8].”
BackgroundLeft-Ventricular Diastolic Dysfunction as a Risk Factor for Dialytic Hypotension
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“1% of the population needs renal replacement treatment.([38]) Therefore, early diagnosis and optimum treatment of DNp, which is the most common cause of ESRD and is gradually increasing in frequency, will positively affect patients’ quality of life as well as lower treatment costs.”
BackgroundPrognosis of Elderly Japanese Patients Aged ≥80 Years Undergoing Hemodialysis
Hatakeyama, S., Murasawa, H., Hamano, I., Kusaka, A., Narita, T., Oikawa, M., Noro, D., Hagiwara, K., Ishimura, H., Yoneyama, T., et al. (2013) · The Scientific World JOURNAL · doi:10.1155/2013/693514 · Cited by 16
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“Reductions in physical well-being in older prevalent dialysis patients compared with age-matched controls were also reported in the North Thames Dialysis Study (37).”
ResultThe effect of a healthy lifestyle program on the elderly′s health in Arak
Shamsi, M., Zamani, M., & Hekmatpou, D. (2013) · Indian Journal of Medical Sciences · doi:10.4103/0019-5359.121119 · Cited by 15
“Since the elderly are considered the vulnerable class in society, they face a number of specific age‐related problems which can be prevented by lifestyle modifications and corrections.[5]”
Background[Functional dependency evaluation of hemodialysis patients: a multicentric study].
Arenas, M. D., Álvarez-Ude, F., Angoso, M., Berdud, I., Antolín, A., Lacueva, J. L., Marcos, S. G., Fernández, A., Mt, G., & Soriano, A. (2006) · PubMed · Cited by 15
Ward, A. J., Salas, M., Jaime, J., & Owens, D. R. (2004) · Cost Effectiveness and Resource Allocation · doi:10.1186/1478-7547-2-2 · Cited by 15
Chaves, L. D. P., Anselmi, M. L., Barbeira, C. B. D. S., & Hayashida, M. (2002) · Revista da Escola de Enfermagem da USP · doi:10.1590/s0080-62342002000200013 · Cited by 14
Impact of Living Environment on 2-Year Mortality in Elderly Maintenance Hemodialysis Patients
Huang, W., Lin, J., Lin‐Tan, D., Chen, K., Hsu, C., & Yen, T. (2013) · PLoS ONE · doi:10.1371/journal.pone.0074358 · Cited by 14
“Several studies [1,13,16] have clearly identified that the severity and number of comorbid illnesses and nutritional status are risk factors associated with mortality in elderly HD patients.”
BackgroundInfluentialSong, Q., Yan, H., Yu, Z., Li, Z., Yuan, J., Ni, Z., & Fang, W. (2021) · Scientific Reports · doi:10.1038/s41598-021-94032-8 · Cited by 14
Tse, D. M. W. (2009) · Hong Kong Journal of Nephrology · doi:10.1016/s1561-5413(09)60243-x · Cited by 14
Schmidt, R. J., Goldman, R. S., & Germain, M. J. (2012) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2012.07.020 · Cited by 14
“Further, there is a substantial time trade-off, with the time of traveling to and from dialysis, time spent on dialysis, and time recovering from dialysis resulting in reduced time available for desired activities.(16,23,24) In one study, compared with patients choosing not to pursue dialysis, hemodialysis patients sp…”
BackgroundPeritoneal dialysis in patients 75 years of age and older--a 22-year experience.
Taveras, A. E., Bekui, A., Gorban‐Brennan, N., Raducu, R., & Finkelstein, F. O. (2012) · PubMed · Cited by 14
Renal 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)00128-5 · Cited by 14
Ravera, M., Re, M., & Vettoretti, S. (2006) · Journal of the American Society of Nephrology · doi:10.1681/asn.2005121323 · Cited by 14
Chronic kidney disease and the aging population
Tonelli, M. A., & RIELLA, M. C. (2014) · American Journal of Physiology-Renal Physiology · doi:10.1152/ajprenal.00063.2014 · Cited by 13
Effect of physical activity on depression symptoms in patients with IgA nephropathy
Zhao, Y., Chen, Y., Wu, Y.-Q., Bao, B., & Fan, H. (2020) · Journal of International Medical Research · doi:10.1177/0300060519898008 · Cited by 12
“A study by Lamping et al.(26) found that the psychological scores of people with illness older than age 70 years were similar to those of their younger counterparts because older people are more likely to accept having a disease than younger people.”
ResultPostma, M. J., & de Zeeuw, D. (2009) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfp352 · Cited by 13
“Other data have shown the average cost of treating ESRD in the UK to be ∼£20 802 (∼€25 000) per patient per year [61] and the annual cost of dialysis to be £30 000 (∼€35 500) [62], whereas ESRD costs in Germany in 1999 were estimated at €40 414 per patient per year [63] and, in France, the estimated annual expenditure…”
Kamar, F. B., Tam‐Tham, H., & Thomas, C. M. (2017) · Canadian Journal of Kidney Health and Disease · doi:10.1177/2054358117718538 · Cited by 13
Why home hemodialysis? A systematic “marketing” analysis
Piccoli, G. B., Ferraresi, M., Consiglio, V., Scognamiglio, S., Deagostini, M. C., Randone, O., Vigotti, F. N., & Calderale, P. M. (2012) · Journal of Nephrology · doi:10.5301/jn.5000088 · Cited by 12
Rights of chronic renal failure patients undergoing chronic dialysis therapy
Andreucci, V. E., Kerr, D. N. S., & Kopple, J. D. (2003) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfg531 · Cited by 12
“Since the elderly are more likely to have co-morbidity, a preponderance of younger patients is likely but not inevitable, since many elderly patients enjoy a good quality of life [6].”
BackgroundThe challenges of renal replacement therapy and renal palliative care in the elderly
Isles, C., Robertson, S., Almond, A. H. G., Donaldson, K., & Clark, D. A. (2011) · The Journal of the Royal College of Physicians of Edinburgh · doi:10.4997/jrcpe.2011.313 · Cited by 12
Quality of Life and Stressors in Patients with Chronic Kidney Disease Depending on Treatment
Martínez‐Sanchis, S., Bernal, M. C., Montagud, J. V., Abad, A., Crespo, J. F., & Pallardó, L. (2015) · The Spanish Journal of Psychology · doi:10.1017/sjp.2015.17 · Cited by 12
Woywodt, A., Meier, M., Kaiser, D., Schneider, G., Haller, H. G., & Hiß, M. (2008) · Peritoneal Dialysis International · doi:10.1177/089686080802800516 · Cited by 12
“39 admissions per IPD-year compare favorably with the literature: The North Thames Dialysis Study previously described hospitalization rates in the region of 2 admissions per patient-year in elderly dialysis patients (23).”
ResultChan, M. F., Wong, F. K. Y., & Chow, S. K. Y. (2010) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2009.03103.x · Cited by 12
Health Care Rationing Affecting Older Persons
Kapp, M. B. (2002) · Journal of Aging & Social Policy · doi:10.1300/j031v14n02_02 · Cited by 11
“There, the practice of physicians in limiting various forms of medical treatment for their patients–from dialysis (Lamping et al., 2000; Moss, 1994) to coronary care unit admission (Dudley & Burns, 1992), hypertension medication (Dickerson & Brown, 1995), and proper cancer treatment (Turner, Haward, Mulley, & Selby, 1…”
BackgroundThe Factors Affecting Survival in Geriatric Hemodialysis Patients
Tuğçu, M., Kasapoğlu, U. S., Sahin, G. M., & Apaydın, S. (2018) · International Journal of Nephrology · doi:10.1155/2018/5769762 · Cited by 11
“Mortality in elderly patients is closely correlated with many comorbidities independent of age [10, 11].”
de Alencar, S. B. V., Dias, L. D. A., Dias, V. D. A., de Lima, F. M., Montarroyos, U. R., & Petribú, K. (2020) · Quality of Life Research · doi:10.1007/s11136-020-02445-1 · Cited by 11
The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia
MacPhail, A., Ibrahim, J., Fetherstonhaugh, D., & Levidiotis, V. (2015) · Seminars in Dialysis · doi:10.1111/sdi.12392 · Cited by 11
“Dementia is also an independent risk factor for death in patients on dialysis (21).”
BackgroundHsieh, C.-Y., Fang, J., Yang, C., Lai, P., Hu, S.-A., Chen, Y.-M., Yu, C., Tian, Y., Chien, C., & Hung, C. (2010) · International Urology and Nephrology · doi:10.1007/s11255-010-9838-0 · Cited by 11
Dialysis outcomes in those aged ≥65 years
Walker, R. J., Derrett, S., Campbell, J., Marshall, M. R., Henderson, A., Schollum, J. B. W., Williams, S., & McNoe, B. (2013) · BMC Nephrology · doi:10.1186/1471-2369-14-175 · Cited by 11
“Inclusion of the KDQoL will make possible the comparison of the SF-36 health status of participants with other groups within New Zealand and also will provide kidney disease-specific information for comparing outcomes with international studies [14-17].”
ResultPalmer, A. J., Valentine, W. J., & Ray, J. A. (2007) · International Journal of Clinical Practice · doi:10.1111/j.1742-1241.2007.01343.x · Cited by 11
Pai, A. B., Smeeding, J. E., & Brook, R. (2004) · Current Medical Research and Opinion · doi:10.1185/030079904125004015 · Cited by 11
McKeaveney, C., Witham, M. D., AlAmrani, A., Maxwell, A. P., Mullan, R. N., Noble, H. R., Shields, J., & Reid, J. (2020) · BMJ Supportive & Palliative Care · doi:10.1136/bmjspcare-2020-002237 · Cited by 10
“(7) A study conducted in the United States 11 reported >75-year olds will account for over 25% of ESRD patients (8), which will carry 12 increased morbidity and mortality issues (9) whereby dialysis may not be suitable in all cases.”
BackgroundIsaacs, A., Burns, A. P., & Davenport, A. (2012) · Blood Purification · doi:10.1159/000337100 · Cited by 10
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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