Chronic peritoneal dialysis in octogenarians

Nada B. Dimkovic1, Sunil Prakash1, Janet Roscoe2, Jane Brissenden2, Paul Tam2, Joanne Bargman1, Stephen I. Vas1 and Dimitrios G. Oreopoulos1,

1 Toronto Western Hospital and 2 Scarborough General Hospital, Toronto, Ontario, Canada



   Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
Background. During the past few decades the pattern of end-stage renal failure disease has changed with increasing number of elderly patients admitted for dialysis. In spite of their increasing number, little is known about the optimal mode of therapy of the ‘old old’ (those >=80 years) patients.

Methods. In this retrospective study, we analysed the results of treatment of 31 non-institutionalized ‘old old’ patients at Toronto Western Hospital (17) and Scarborough General Hospital (14) and seven institutionalized patients in chronic care, Riverdale Hospital. The patients were on CAPD with Twin-bag Baxter (28) or Home Choice, Baxter or Fresenius CCPD system (10). Patients were screened at the CAPD clinic when routine blood investigations were done. Patient and technique survival, initial and final laboratory data (last visit or before death) and complications related/unrelated to dialysis method are presented.

Results. Multiple comorbid conditions were present at the start of the treatment and new added during treatment; very few were dialysis-related. The majority of non-institutionalized patients required assistance of home-care nurse to perform dialysis. Peritonitis (1/28.6 patient months) and exit-site infection rate (1/75.1 patient months) were low and responded to treatment. Incidence of peritonitis was higher among institutionalized debilitated patients (1/5.3 patient months). Incidence of hospitalization was 1/14.7 patient months and patients spent in hospital 7.5 days/patient year. Forty-seven per cent of patients survived 24 months; 39% survived 30 months. Technique survival was 91.5% at 12 months and 81.4% at 30 months. Poor appetite and malnutrition were frequent among very old patients. Patients and their families were motivated for treatment and discontinuation of dialysis was not higher than described elsewhere in literature.

Conclusions. This study has demonstrated that chronic peritoneal dialysis could be recommended as a safe and suitable modality of treatment of end-stage renal failure in old old patients.

Keywords: chronic peritoneal dialysis; institutionalized; non-institutionalized; octogenarians



   Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
During the last few decades the pattern of end-stage renal disease (ESRD) has changed with the increasing number of elderly patients admitted for dialysis [1]. As a result, nephrologists now are confronted with the special needs of an elderly population that differ from those of younger patients. Although the role of chronic peritoneal dialysis (CPD) in elderly has been confirmed, this modality still is underutilized; in part perhaps because the ‘old old’ (those >=80 years) cannot perform ‘self’ dialysis, contrary to the ‘young old’ (those 65–80 years).

In spite of their increasing numbers, we know little about the outcome of the elderly on CPD, about modality-related complications, and about their quality of life (QOL). Most of the existing data have been obtained from dialysis registries and only a few of those publications have dealt with this specific population [24].

The aim of this study was to review, retrospectively, the results of treatment of 38 ‘old old’ patients and to examine certain important aspects of their management, such as complications, survival, and QOL.



   Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
Non-institutionalized patients
In this retrospective study we analysed all elderly patients 80 years and over at the time of initiation of dialysis in the period between January 2, 1995 and March 31, 2000 at the Toronto Western Hospital (TWH) and between January 1998 and March 31, 2000 at the Scarborough General Hospital (SGH). Seventeen such patients at the TWH and 14 at the SGH, had been on CPD for at least 3 months. In all of them, CPD was the first mode of treatment and after receiving adequate information, it was their personal choice. Twin-bag® Baxter or Fresenius system was used in CAPD patients and Home Choice®, Baxter or Freedom Cycler, Fresenius for CCPD. In 26 patients of the 31 patients, a home-care nurse was responsible for bag selection and exchanges for two to four daily exchanges. Nurses also were involved in erythropoietin injections (12 patients), blood pressure (26 patients), weight (26 patients) and glucose control (10 patients), and exit-site monitoring. There was close communication between home-care nurses and dialysis nurses. Dialysis prescription was based mainly on clinical and biochemical data. Patients were seen at the CAPD clinic every 4–6 weeks when routine blood investigations were carried out. These included serum cholesterol (total, HDL, LDL), triglycerides, total iron, iron saturation, ferritin, alkaline phosphatase, intact parathyroid hormone, and liver enzymes. In dialysis prescription, we followed DOQI guidelines. This paper presents only initial and final data (done at the time of the last clinic visit or before death or discontinuation of PD) as there were no significant changes in above-mentioned parameters during follow-up period.

Peritonitis was diagnosed in the presence of at least two of the following: abdominal pain, cloudy effluent with more than 100 WBC/mm3, and positive dialysate culture. Exit-site infection was diagnosed in the presence of serous or purulent discharge accompanied by a positive swab [6]. Peritonitis rate and exit-site infection rate were expressed as one episode per patient months.

In calculating technique survival, we considered as end events all ‘dropouts’ due to complications of PD, including deaths due to PD (peritonitis).

Hospitalization rate was expressed as one admission per patient years (total number of hospitalizations/total follow-up years) and as number of hospital days per patient year.

Institutionalized patients
During the period of the study (1995–2000) seven patients, not included in the previous group, were treated with CPD in a chronic care hospital in Toronto (Riverdale Hospital, RH). Of these seven patients, six were on chronic dialysis before admission to the RH: five on CPD for 10–30 months and one on HD for 8 months. On admission they were treated with CAPD (three patients) and APD (three patients). One patient started PD in hospital and, soon after, was transferred to the RH. All seven patients were institutionalized because of deterioration of their general condition; they could not be managed at home but did not require acute hospital treatment.

QOL was presented retrospectively according to scale included into charts: during the visits patients were asked if they feel very well, well, poorly, or very poorly. Data about dizziness, lethargy, and depression were included as well as the patient's capacity to control their bladder and stool function, and capability to perform dialysis and daily activities.

Due to differences between the groups, some data from non-institutionalized patients are presented separately from that of institutionalized patients.

Data are presented as mean±SD. Significant differences between two groups were calculated by unpaired Student's t-test or by {chi}2-test. Survival rates were calculated according to Kaplan and Meier and survival curves were compared by the Wilcoxon test.



   Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
Characteristics of patients
Table 1Go shows patient demographics. Overall there were 31 patients, 17 at the TWH and 14 at the SGH (non-institutionalized patients); their mean age was 83.5±3.27 years (range 80–95) with predominance of males (64.5%). The seven patients in RH were of similar age (85.1±4.54, range 80–90) and sex distribution. The non-institutionalized patients were followed-up for a mean period of 15.0±10.1 months (range 3–35); institutionalized patients were followed 3.5±2.5 months (range 1.5–8) after hospitalization.


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Table 1. Patient demographics

 
The most common cause of renal failure in these two groups was hypertension (32 and 29%) and diabetes mellitus type 2 (32 and 57%), respectively. Among comorbid conditions, most frequent in both groups were hypertension (68 and 71%), coronary artery disease (29 and 86%), peripheral vascular disease (26 and 28%), and seriously impaired vision (26 and 29%). Seventy-six per cent of non-institutionalized patients and 100% of institutionalized patients had more than three diagnoses apart from underlying renal disease.

In all non-institutionalized patients PD was the modality of first choice. CAPD was applied in 18 non-institutionalized (58%) and in five institutionalized patients (71%) and APD in the rest. Two non-institutionalized patients switched from CAPD to APD during the follow-up period.

Of the 31 non-institutionalized patients, only two were able to perform dialysis by themselves and four were able to participate in it. Family members assisted in the dialysis procedure in five patients; home-care nurses were involved in the care of 24 patients. These nurses were involved in bag selection and exchanges, erythropoetin treatment, glucose, weight, and blood pressure control. In all institutionalized patients, dialysis was performed by hospital nurses.

Laboratory data
Laboratory data of non-institutionalized patients are presented in Table 2Go. Creatinine clearance (Ccr), which was measured in 17 patients (TWH), showed that all had a small residual renal function at the start of dialysis with Ccr ranging between 3.3 and 10 ml/min. There was only a small decline in residual renal function during the follow-up. We noted a significant improvement in haemoglobin, iron, and iron saturation levels during the course of therapy. BUN, phosphorus, serum albumin, serum proteins, serum calcium, PTH, alkaline phosphatase, and cholesterol levels did not change significantly during the follow-up period.


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Table 2. Laboratory data of the institutionalized and non-institutionalized patients

 
In institutionalized patients, haemoglobin increased and serum phosphorus, proteins, and albumin decreased significantly.

Peritonitis
Rates
Fifteen patients (48.4%) did not develop peritonitis during follow-up period of 11.3±6.9 months (range 4–30). The remaining 16 non-institutionalized patients had 16 episodes of peritonitis over the 457 patient months of follow-up, a rate of 1/28.6 patient months. The most frequent organisms responsible for peritonitis were Staphylococcus epidermidis in six cases (37.5%), and Gram-negative organisms in four cases (25%).

Outcome
Eleven of the 16 patients with peritonitis had a good outcome and all continued on CAPD. In three patients, the peritoneal catheter had to be replaced because of obstruction, two of these three continued on CPD; two patients switched to HD and one patient with peritonitis and cachexia died.

Among the seven institutionalized patients, five patients had five episodes of peritonitis over a follow-up period of 26.5 months, a rate of 1/5.3 patient months. The main organism responsible was Staph. epidermidis in two (40%). One peritonitis episode was ascribed to a complication of percutaneous gastrojejunostomy in a patient unable to eat. Peritonitis had a good outcome in four patients; one patient died.

Exit-site infection
Twenty-six of the 31 non-institutionalized patients (83.9%) had no exit-site infection during the follow-up period. The remaining five had six episodes of exit-site infection—an overall incidence of one episode per 76.1 patient months. The causative microorganisms were: Staphylococcus aureus in two and Diphteroid microorganisms, Seratia marcense, Pseudomonas aeruginosa and Streptococcus viridans in one patient each. Exit-site infection did not require catheter replacement in any patient.

No institutionalized patients developed exit-site infections.

Hernias
Five non-institutionalized patients developed hernias: three of them had an inguinal hernia, one an umbilical and one had both inguinal and umbilical. All hernias were repaired successfully using Marlex plug and patch and patients were able to continue on CPD. No institutionalized patients developed a hernia.

Catheter complications
We encountered five catheter-related complications (outflow problems) only in non-institutionalized patients. Catheter removal was necessary in four patients due to outflow obstruction: in three, this complication developed after peritonitis, and in one it was unrelated to peritonitis. In two of these four patients, the catheter was replaced and two patients switched to HD after catheter removal. One malpositioned catheter was relocated using a guidewire.

Hospitalization
Those 31 non-institutionalized patients had one clinic visit per 1.8 patient-months and 31 hospital admissions during an overall follow-up period of 457 months (1/14.7 patient months). They spent a total of 250 days in hospital—a rate of 7.5 days/patient year. Peritonitis was the main reason in 22.6% of all hospitalizations (Table 3Go).


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Table 3. Incidence and outcome of peritonitis in institutionalized and non-institutionalized patients on PD

 

Conditions developed after the start of PD
During the follow-up period, non-institutionalized patients developed the following conditions: in two, severe depression leading to anorexia and malnutrition, in one each skeletal metastasis of unknown origin, antral and duodenal ulcer, severe dysphagia, requiring nasogastric tube feeding, pulmonary embolism, dementia with psychotic symptoms (hallucination), neurogenic bladder and UTIs, essential tremor, and mild parkinsonism.

In six of seven institutionalized patients, their overall condition deteriorated rapidly after admission. They developed aspiration pneumonia, haematemesis, stroke, cellulitis, Clostridium difficile colitis, and malnutrition. One patient with fracture of the humerus was rehabilitated and discharged home after 2.5 months.

QOL
At the beginning of the PD therapy, all non-institutionalized patients had control of bladder and stool function. All were mentally competent and had good social interaction with family members. However, most of them required partial or total assistance with PD (93.5%) and 70% required some degree of assistance with their daily activities.

During the follow-up period, the most frequent complaint was poor appetite (in 12, 38.7%); fatigue in 16 (51.6%), lethargy in six (19.3%), dizziness in five (16.1%), and depression in four (12.9%). At the end, all patients were dependent to some degree not only for their dialysis performance but for their daily activities, i.e. dressing, toileting, bathing, walking. Three patients became dependent on total care.

Despite the multiple complications at the start of treatment these patients indicated that they felt very well (41%) or well (28%) and poorly (29%) or very poorly (2%). At the end of therapy, some had deteriorated, 42% felt well or very well (vs 69% at the start), and 58% poorly or very poorly (vs 31%).

All seven institutionalized patients were incontinent of stool and urine; they spent most of their time in bed and required total care. Only two of the seven were mentally competent and did not show any signs of depression, anxiety, or bad mood. The other five were confused or unable to communicate, showed highly reduced social interaction, were unable to answer questions and showed lack of judgement. Their appetites deteriorated as their overall mental and medical condition became worse.

Outcome
All patients
Of these patients, 72% survived 12 months, 47% 24 months, and 39% 30 months (Figure 1Go).



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Fig. 1. Patient and technique survival of 38 ‘old old’ patients on CPD.

 

Non-institutionalized patients
Of these patients, 78% survived 12 months, 49% 24 months, and 36% 30 months. At the time of this report, 18 patients continue on PD after 5–30 months of treatment. Ten patients (32.2%) died after an average of 16 months of treatment (range 4–35 months). Reasons of death were: withdrawal (three patients), infection (three patients), cachexia (two patients), stroke (one patient), and peritonitis (one patient). Two patients switched to HD because of persistent peritonitis and one continued PD treatment in another hospital.

Institutionalized patients
Of seven institutionalized patients, five died, one recovered after rehabilitation following the fracture of the humerus and one is still alive after 6 months of therapy. The causes of death were aspiration pneumonia, stroke, malnutrition, cardiac failure, and peritonitis. Mean survival in the institution was 6.3±2.1 months (Figure 1Go).

Withdrawal
In three non-institutionalized patients (9.7% of all patients) PD was stopped (30% of all deaths). One patient asked to withdraw at a time when he was mentally competent. In two others, dialysis was stopped after consultation with family members; because of overall disability following acute myocardial infarction, and in another patient because of cachexia. Despite the severity of their comorbid conditions dialysis was not withdrawn in any institutionalized patient.

Technique survival
Technique survival among all 38 patients (31 non-institutionalized and seven institutionalized) was 91.5% at 12 months and 81.4% at 30 months (Figure 1Go).

Comparison between two different periods
Data from two different periods in the TWH are presented in Table 4Go. In both periods (1990–1995 and 1995–2000), the incidence of ‘old old’ patients on CPD, mean age, and sex distribution are similar. However, in the latest period, there were more diabetic patients (32.2 vs 11%) and more patients with impaired vision. Also, more patients had more than three additional illnesses apart from ESRD (77 vs 67). However, modality-related complications were less frequent in the recent period: peritonitis rate (1/28.6 vs 1/10.8 patient months), exit-site infection (1/75.1 vs 1/41.8 patient months), catheter-related complications (five vs 10). Hospitalizations were also less frequent (rate 1/14.7 vs 1/8 patient months). In the most recent period peritonitis was a cause of hospital admissions in 22.6% of patients and cause of death in 10% that is significantly lower than in the period 1990–1995. Probably because the patients were sicker in the most recent period, overall survival was lower (49% at 2 years) than in early period (80% at 3 years).


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Table 4. Results of treatment of ‘old old’ patients in TWH in two different periods (1990–1995 and 1995–2000)

 



   Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
This paper shows that elderly patients can be successfully treated with PD if they have proper family and social support. In our group family members were involved in the dialysis of only five patients; in the remaining 26 non-institutionalized patients, home-care nurses were actively involved in the dialysis but also in the overall medical care. Our findings agree with those of Issad et al. [4], who concluded that CAPD performed by trained home-care nurses provides the elderly with a comfortable and safe home dialysis without reliance upon other family members. There were no significant differences in the rates of peritonitis and exit-site infections between those on ‘self dialysis’ and those on ‘assisted dialysis’ by home-care nurse [2].

The rate of acceptance of elderly patients for dialysis treatment differs between countries and even among different units. With the exception of Canada, UK, and Scandinavian countries, the number of elderly patients treated with PD remain very low in many countries. In our units, whenever there is no contraindication for a particular modality the patient is asked to choose between HD and PD. ‘Old old’ patients make up 5.6% of the total PD population in TWH and 7.9% in SGH. The predominance of males has been described in previous series. In agreement with others [1,2,4,5], hypertension and diabetic nephropathy—two conditions known to be associated with higher morbidity and mortality, were the leading cause of renal disease. The rate of comorbid factors was very high. At the start of therapy 76% of non-institutionalized and 100% of institutionalized patients had more than three additional diseases. This is significantly more than that of elderly patients older than 65 years among whom 30% of patients had three or more additional diagnoses [3,6]. As in other series [3,5], hypertension, coronary artery disease, peripheral vascular disease, and seriously impaired vision due to diabetes were the most frequent comorbid illnesses.

The elderly are at increased risk of infection for reasons such as immunodeficiency, malnutrition, and high rate of bowel diseases. Our group of non-institutionalized patients developed peritonitis at a rate of one episode per 28.6 patient months; this result is better than that reported by others [2,4,7,8]. The peritonitis rate was higher among institutionalized than among non-institutionalized patients (l/5.3 vs 1/28.6 patient months). Those patients were on CAPD up to 30 months before institutionalization. In the meantime they deteriorated significantly; they became malnourished, incontinent, and bedridden. Our results are in agreement with previous observation that bedridden, seriously ill and malnourished patients tend to have a higher peritonitis rate [9].

Exit-site infection was rare; it was significantly lower than that usually reported by other authors and we did not observe tunnel infection at all. Our findings are consistent with the observations of others that exit-site infection, tunnel infection, and leak are low in elderly patients on PD because they are less active than younger patients [8,10]. During the 457 months of follow-up period there were only five catheter-related outflow problem, mainly due to previous peritonitis episode; only two of them switched to HD after catheter removal. According to the literature data, this complication was not more frequent than in younger group of patients.

Although the higher incidence of hernia in elderly persons has been attributed to weakness of the abdominal wall, the incidence of hernia in our population of ‘old old’ patients was not high, and had no influence on the course of dialysis.

QOL is difficult to assess in a retrospective study. According to our data, QOL is influenced by the patient's mental status, ability to control bladder and stool, and general mobility. All our non-institutionalized patients were mentally competent and had good interaction with family members and staff. About 69% of these patients reported to feel well or very well at the beginning of the study and all were motivated to continue treatment. Institutionalized patients, who were mentally competent did not show any sign of depression, anxiety, or bad mood. However, with time on dialysis some patients showed deterioration in QOL.

Of the few studies that have been done on QOL in the elderly on CPD, some show that dementia and severe depression are more frequent in those who required help with dialysis [2,7].

However, it seems that elderly patients are more tolerant and less stressed about dialysis procedure than are younger ones or those on HD. Also, they had a greater sense of well being than those on in-centre HD [11].

Hospitalization rates are said to be higher in elderly than in younger patients, especially among blacks and diabetics [2]. Our patients spent 7.5 days per patient year, a rate significantly lower than that reported by others [9,12]. No differences were reported in the literature in hospitalization rates between elderly patients on PD and HD [6].

The overall survival of these 38 elderly patients was 72% at 12 months, 47% at 24 months, and 39% at 30 months. Our survival rate is similar to that observed by Woodhouse et al. [13] and better than that observed by others [3,14]. However, our survival rates are lower than in our previously published data (80% survival rate at 3 years) [2] or data presented by Schaffer et al. [15] most probably due to higher number of diabetics and those with comorbid conditions in more recent period.

Data about CPD in institutions (chronic care units or nursing homes) are scarce. Most of the nursing homes provide HD and only 10% provide CPD [16]. Patients in nursing homes have a shorter survival than do the general CPD elderly population, probably because of serious comorbid factors and advanced age. Our findings confirm the low survival of institutionalized ‘old old’ patients but their low survival is due to their serious comorbid illnesses, which were the main cause of institutionalization. Institutionalized patients had low total proteins and albumin levels at institutionalization and these values deteriorated further during the follow-up. Mignon et al. [17] believed that low initial albumin level is a risk factor for mortality among elderly patients on CPD. Also, malnutrition was more frequent in the elderly than in younger PD populations and it highly correlated with patients survival [4,7] and cachexia was a frequent cause of death [16]. According to literature data, cachexia was not more frequent in PD than in HD elderly patients [18].

Withdrawal from dialysis is the cause of death in up to 40% of deaths. In our non-institutionalized patients, we stopped dialysis in three (30% of all deaths). Although many assert that withdrawal from dialysis is more frequent among institutionalized patients [19], relatives asked for withdrawal of dialysis in none of our institutionalized patients.

Technique survival in elderly is said to be similar [8] or even better than that in younger patients on CPD [18]. Such survival in our group of patients was very high: 91.5% for 12 months and 81.4% for 30 months.



   Conclusion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 
CPD can be performed successfully in very old patients. Most ‘old old’ patients require assistance to perform their dialysis and to carry out activities of daily living. Close attention should be paid to the psychosocial support of those elderly. The most complicated cases (those with mental and physical disability) require a widespread network of medical and social support (home-care nurse, rehabilitation and chronic care dialysis units, dialysis in nursing homes). Elderly patients have no higher modality-related complications than younger. Poor appetite and malnutrition were frequent among the very old and nutritional surveillance should be addressed rigorously. Patients and their families were motivated to treatment and the discontinuation of dialysis in these patients was not higher than that described elsewhere in literature. Although general recommendation does not exist and every patient should be considered as individual, CPD can be recommended as safe and suitable modality of treatment of ESRD in ‘old old’ patients.



   Notes
 
Correspondence and offprint requests to: Dimitrios G. Oreopoulos, Division of Nephrology, The Toronto Hospital, Western Division, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Email: dgoreopoulos{at}msn.com Back



   References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 

  1. US Renal Data System. 1999 Annual Data Report: National Institutes of Health, National Institutes of Diabetes, Digestive and Kidney Disease. Bethesda, MD, April 1999
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Received for publication: 22.11.00
Revision received 16. 5.01.



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