Currently, more than 400,000 people year go on dialysis, with a third of them 65 or older with multiple serious health complications accounting for 42% of the costs. Now, kidney experts are shining an uncomfortable spotlight on the subject of a law passed by Congress that provides for nearly free care to almost all kidney failure patients.
Although the law was conceived to keep otherwise healthy younger/middle-aged people alive for years of further productivity. In reality the patients most often served by the law are elderly patients using dialysis as a replacement for their failed kidneys for a short time, until they perish from other chronic diseases.
Kidney specialists are suggesting that elderly patients that qualify for free dialysis should be pushed by their doctors to chose instead ” “medical management without dialysis”, for example hospice care, arguing that such patients for whom death is imminent are ultimately better served guided toward palliative care rather than the free dialysis program.
The Renal Physicians Association recently formulated guidelines for doctors to use in deciding when dialysis is appropriate, including questions such as “Would I be surprised if this patient is dead within a year?” to help them decide when medical care is better diverted to palliative measures than dialysis.
Kidney failure patients spend 2-3 hours at least three days a week hooked up to a dialysis machine. The treatment alleviates fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, and nausea, as well as infections and stenosis of the vessels pierced by dialysis needles.
Specialists say its important that doctors do not hide these truths from patients, but rather arm them with realistic information about their imminent death, to aid in decision making about end-of-life care (for example, sharing the findings from studies that show that 1) dialysis does not prolong life for many elderly people with comorbidities, while having a significant impact on quality of life and 2) that dialysis is a significant predictor of patients dying in the hospital rather than at home).
The problems facing the program (and the population) are multifold: patients given the choice for free dialysis show a strong preference for extending their lives – even greatly debilitated – for even a short time; baby boomers are swelling the ranks of those eligible for dialysis, and, of course money: end-stage kidney disease will cost the us a projected $50 billion in 2011 this year, an astronomical figure that will only increase given that the largest generational demographic cohort ever to move through the population i.e. baby boomers – are aging into diseases such as Type II diabetes, which is the leading cause of kidney failure, accounting for 44% of new cases each year.
According to the American Diabetes Association, nearly 50,000 people in the US with diabetes begin treatment for end-stage kidney disease each year. In just the past three years, the number of people receiving with end-stage kidney disease due to diabetes living on chronic dialysis has more than doubled.
But dialing back participation in the free federal dialysis program is not going to be easy. It is difficult for some patients to grasp the the gravity of their disease and their end of life health care choices. But even more, when given the chance to extend their lives – even greatly debilitated lives, even for a short time – most patients cannot refuse the offer.
As one elderly dialysis patient put it in the NY Times story, ” “When you …sit and think about how good life is, what choice do you really have? he poignantly asked. Another patient put it more succinctly, requesting dialysis even though her health problems death from complication a strong likelihood. “Some life is better than no life,” she pointed out.
The Transplant Option
Clinical studies show that the longer a patient is on dialysis, the greater the risk of cardiovascular damage, which has a negative impact on a patient’s candidacy for transplant. A transplant, whether cadaveric (i.e. from a deceased person) or from a living donor improves a ESRD patient’s quality and length of life, and research shows that transplant outcomes are superior for end stage kidney failure patients who spend no/less time on dialysis.
As well, data from UNOS shows that a transplanted kidney from a living donor has better survival odds than a kidney transplanted from a cadaver. Today there are more than 150,000 people in the US living with transplanted kidneys.
The issue of course is availability of organs. In the US, an ESRD patient waits on average more than 5 years for an organ, and more than 15 die each day waiting for an organ to become available. The first instance of living kidney donation (between brothers) occurred in the 1950s; since then, living kidney donation has become increasingly common, driven by a number of factors, including:
the advent of laparoscopic techniques in 1995, making the nephrectomy procedure far less invasive and therefore dangerous
the development of anti-rejection drugs (reducing the need for tissue-matching between biologically related donor and recipient)
the proliferation of internet web sites that connect patients needing a kidney with unrelated prospective donors
the growth of medical travel, giving patients access to sophisticated transplant teams at state-of-the-art international hospitals for a fraction of skyrocketing US costs