Do demographic variables affect the timing of referral to the nephrologist?

The consequences of late referrals for nephrological care include: increased morbidity, poorer quality of life on dialysis and probably increased mortality. Few studies look at the socio‐demographic factors which influence referral to the nephrologist. There is good evidence from studies in other areas of health care that socio‐demographic and economic factors influence access to health care. It is important that the nephrology community understand whom the individuals are who likely to be referred late so that we can address any inequality in access to services. We studied all of the patients who started renal replacement therapy in our unit over a five‐year period, 1^st January 1996 to 31^st December 2000 (n = 494). We collected data on gender, age at referral, ethnicity, the date that the individual started dialysis as well as the date they were first seen by a nephrologist. We analysed the data to see if age, gender or ethnicity was associated with timing of referral. If an individual had seen a nephrologist more than three months prior to starting dialysis, they were termed ‘early referred’, if not they were termed ‘late referred’. Since this was a sociologically driven research project, we set statistical significance at the 10% (0.1) level. Our data showed that gender did not affect the timing of referral (p = ns), ethnicity affected referral in so much as whites were more likely to be referred late than blacks (p = 0.08) but no more so than non‐whites (p = ns). People under the age of 30 were statistically more likely to be referred late than people over the age of 30 years (p = 0.027) as were people under the age of 40 (p = 0.047). We interpret these finding as demonstrating that health care professionals are referring older people and people from the black community in good time and that, in contrast to other studies of inequalities in health, these findings demonstrate that the elderly and ethnic minorities are not being disadvantaged.     

Race and restless sleep complaint in older chronic dialysis patients and nondialysis community controls

There is mixed evidence about the relation of race to risk of sleep disturbance. We explored the relation of race to restless sleep complaint in survey data from a cohort of 311 older patients undergoing chronic renal dialysis and a similarly aged cohort of 354 nondialysis controls. Older dialysis patients were significantly more likely to report restless sleep. Restless sleep complaint was related to comorbidity, depressed mood, use of sleep medications, and perceived health status in both groups. Black patients in the dialysis cohort had decreased odds of restless sleep, but Black and White controls did not differ significantly in reporting restless sleep. Compared with their more socially advantaged White counterparts, older Black dialysis patients may perceive the chronic dialysis care environment more favorably. The findings are consistent with the view that sleep quality in late life is likely to reflect a delicate balance between psychological as well as physical well-being.     

Racial and ethnic disparities in influenza vaccination among elderly adults

Objectives: To examine whether access to care factors account for racial/ethnic disparities in influenza vaccination among elderly adults in the United States.
Design: Indicators of access to care (predisposing, enabling, environmental/system, and health need) derived from Andersen's behavioral model were identified in the National Health Interview Survey questionnaire. The relationship of these indicators to influenza vaccination and race/ethnicity was assessed with multiple logistic regression models.
Main Results: Significant differences in vaccination were observed between non-Hispanic (NH) whites (66%) and Hispanics (50%, P <.001) and between NH whites (66%) and NH blacks (46%, P <.001). Controlling for predisposing and enabling access to care indicators, education, marital status, regular source of care, and number of doctor visits, reduced the prevalence odds ratios (POR) comparing Hispanics to non-Hispanic whites from 1.89 to 1.27. For NH blacks, controlling for access to care indicators changed the POR only from 2.24 (95% CI, 1.9 to 2.7) to 1.93 (95% CI, 1.6 to 2.4).
Conclusions: This study confirmed the existence of sizable racial/ethnic differences in influenza vaccination among elderly adults. These disparities were only partially explained by differences in indicators of access to care, especially among non-Hispanic blacks for whom large disparities remained. Factors not available in the National Health Interview Survey, such as patient attitudes and provider performance, should be investigated as possible explanations for the racial/ethnic disparity in influenza vaccination among non-Hispanic blacks.     

高龄终末期肾衰竭病人不同治疗方式的临床疗效观察

目的 比较高龄(≥80岁)终末期肾衰竭病人采取不同治疗方式的临床疗效,探讨适合高龄终末期肾衰竭病人的治疗方式.方法 收集本院5年间诊治的高龄终末期肾衰竭病人59例,其中18例采取单纯药物治疗,22例行常规血液透析(HD)治疗,19例以保留残余肾功能为目的进行低剂量透析治疗,比较3组间生命体征、血液生化指标、预后等指标的...     

Crohn's disease: does race matter? The Mid-Atlantic Crohn's Disease Study Group

OBJECTIVE: The severity of Crohn's disease (CD) has been reported to be greater in blacks than in whites. This possible disparity may be due, in part, to differences between these groups in health care utilization and accessibility. To explore these issues, we conducted a multicenter survey of patients with CD. METHODS: One-hundred and forty-five blacks with CD, recruited from four teaching hospitals and five private practices, and identified by medical record review or ICD-9 code, were enrolled and matched to 407 whites with CD (by age, gender, and practice type [teaching vs. private practice setting]). Participants were interviewed regarding medical history, health status, personal health care practices during the preceding 5 yr, and beliefs regarding health care in the general population. RESULTS: Blacks and whites were similar with respect to age of CD onset, lag in time to diagnosis, and number of gastrointestinal (GI)-related hospitalizations and surgeries. Medication usage patterns were also similar in the two groups. Quality of life, measured by SF-36, was lower in all categories for blacks, compared with whites. Blacks were more likely to have had to stop work (p<0.01) and have lost more work days (p<0.01) than were whites. Whites were more likely to have health insurance and be able to identify a regular provider than were blacks. Blacks were more likely to report the following: receiving Medicaid; difficulty affording health care; delaying appointments due to financial concerns; difficulty traveling to their provider's office; and experiencing unreasonable delays at their provider's office. After adjusting for potential confounding variables, we found no differences between the groups, except for the number of days of work lost because of CD. CONCLUSIONS: These data suggest that black and white patients have similar reported disease presentations and course, and contrast with prior reports suggesting a more severe disease course among black patients. Although the disease itself appears similar, there were numerous reported differences between the races in health care utilization practices and in disease impact upon daily activities. We suggest that apparent disparities in CD according to race are actually due to social and economic factors, and not to the disease itself.     

Do demographic variables affect the timing of referral to the nephrologist?

The consequences of late referrals for nephrological care include: increased morbidity, poorer quality of life on dialysis and probably increased mortality. Few studies look at the socio-demographic factors which influence referral to the nephrologist. There is good evidence from studies in other areas of health care that socio-demographic and economic factors influence access to health care. It is important that the nephrology community understand whom the individuals are who likely to be referred late so that we can address any inequality in access to services. We studied all of the patients who started renal replacement therapy in our unit over a five-year period, 1st January 1996 to 31st December 2000 (n = 494). We collected data on gender, age at referral, ethnicity, the date that the individual started dialysis as well as the date they were first seen by a nephrologist. We analysed the data to see if age, gender or ethnicity was associated with timing of referral. If an individual had seen a nephrologist more than three months prior to starting dialysis, they were termed 'early referred', if not they were termed 'late referred' Since this was a sociologically driven research project, we set statistical significance at the 10% (0.1) level. Our data showed that gender did not affect the timing of referral (p = ns), ethnicity affected referral in so much as whites were more likely to be referred late than blacks (p = 0.08) but no more so than non-whites (p = ns). People under the age of 30 were statistically more likely to be referred late than people over the age of 30 years (p = 0.027) as were people under the age of 40 (p = 0.047). We interpret these finding as demonstrating that health care professionals are referring older people and people from the black community in good time and that, in contrast to other studies of inequalities in health, these findings demonstrate that the elderly and ethnic minorities are not being disadvantaged.     

Effects of gender and ethnic group on blood pressure control in the elderly

In order to determine the adequacy of blood pressure treatment in black and white elderly men and women, the authors performed a cross-sectional population survey in Central North Carolina in 1986–1987. Participants included a random sample of noninstitutionalized individuals age 65 years or older. Blacks were oversampled. A health questionnaire was administered, and blood pressure was measured. Of 5,223 eligible persons, 4,162 (80%) participated. Fifty-four percent of subjects were black and 65% were women. Sixteen percent of the study subjects were white men, 30% white women, 19% black men, and 35% black women. The mean age was 73 years. Fifty-three percent had hypertension. Among hypertensives, 80.8% were taking blood pressure medication. Among treated hypertensives, blood pressure was adequately controlled, (measured diastolic blood pressure of 90 mm Hg or lower) in 85.6%. Women were 52% more likely than men and blacks were 40% less likely than whites to exhibit adequate blood pressure control. Older age and smoking were also associated with better blood pressure control. The authors conclude that hypertension is more likely to be controlled in elderly women than men and less likely to be well-controlled in elderly blacks than whites. The choice of antihypertensive agent may also be important. Further investigation is needed into the mechanisms accounting for the observed sex and race differences.     

Racial,ethnic, and affluence differences in elderly patients' use of teaching hospitals

OBJECTIVE: To understand the role of race, ethnicity, and affluence in elderly patients' use of teaching hospitals when they have that option. METHODS: Using a novel data set of 787,587 Medicare patients newly diagnosed with serious illness in 1993, we look at how sociodemographic factors influence whether patients use a teaching hospital for their initial hospitalization for their disease. We use hierarchical linear models to take into account differences in the availability of teaching hospitals to different groups. These models look within groups of people who live in the same county and ask what demographic factors make an individual within that county more or less likely to use a teaching hospital. RESULTS: We find that blacks are much more likely than whites to use teaching hospitals (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.73 to 1.77). However, Hispanics and Asian-Americans are less likely to use teaching hospitals than are whites (Hispanic OR, 0.92; 95% CI, 0.88 to 0.97; Asian-American OR, 0.89; 95% CI, 0.82 to 0.97). Medicaid patients are less likely to use teaching hospitals (given their opportunities) than are non-Medicaid recipients (OR, 0.91; 95% CI, 0.90 to 0.92). And we find a curvilinear relationship with affluence, with those in the poorest and those in the wealthiest neighborhoods most likely to use a teaching hospital. CONCLUSION: The use of teaching hospitals is more complex that heretofore appreciated. Understanding why some groups do not go to teaching hospitals could be important for the health of those groups and of teaching hospitals.     

Black-white disparity in disability: the role of medical conditions

OBJECTIVES: To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors. DESIGN: Cross‐sectional analysis of a community‐based cohort. SETTING: Urban and rural counties of central North Carolina. PARTICIPANTS: Two thousand nine hundred sixty‐six adults aged 68 and older participating in the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). MEASUREMENTS: Self‐reported data on sociodemographic characteristics and medical conditions, Short Portable Mental Status Questionnaire, activities of daily living (ADLs). RESULTS: Fifty‐five percent of the cohort was black. Blacks were more likely than whites to report disability (odds ratio=1.39, 95% confidence interval= 1.15–1.68). Controlling for age, sex, marital status, and socioeconomic status, blacks were more likely to be obese and have diabetes mellitus, and less likely to report vision problems, fractures, and heart attacks. The higher prevalence of obesity and diabetes mellitus in blacks, after adjustment for sociodemographic factors, accounted for more than 30% of the black–white difference in disability. Conversely, the black–white disability gap would be approximately 45% wider if whites had a lower prevalence of fractures and vision impairment, similar to their black peers. CONCLUSION: Higher rates of obesity and diabetes mellitus in older black Americans account for a large amount of the racial disparity in disability, even after controlling for socioeconomic differences. Culturally appropriate interventions that lower the prevalence or the functional consequences of obesity and diabetes mellitus in blacks could substantially decrease this racial health disparity.     

Racial differences in opioid use for chronic nonmalignant pain

BACKGROUND: Chronic pain is a frequent cause of suffering and disability that negatively affects patients' quality of life. There is growing evidence that disparities in the treatment of pain occur because of differences in race. OBJECTIVE: To determine whether race plays a role in treatment decisions involving patients with chronic nonmalignant pain in a primary care population. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey was administered to patients with chronic nonmalignant pain and their treating physicians at 12 academic medical centers. We enrolled 463 patients with nonmalignant pain persisting for more than 3 consecutive months and the primary care physicians participating in their care. RESULTS: Analysis of the 397 black and white patients showed that blacks had significantly higher pain scores (6.7 on a scale of 0 to 10, 95% confidence interval (CI) 6.4 to 7.0) compared with whites (5.6, 95% CI 5.3 to 5.9); however, white patients were more likely to be taking opioid analgesics compared with blacks (45.7% vs 32.2%, P<.006). Even after controlling for potentially confounding variables, white patients were significantly more likely (odds ratio (OR) 2.67, 95% CI 1.71 to 4.15) to be taking opioid analgesics than black patients. There were no differences by race in the use of other treatment modalities such as physical therapy and nonsteroidal anti-inflammatories or in the use of specialty referral. CONCLUSION: Equal treatment by race occurs in nonopioid-related therapies, but white patients are more likely than black patients to be treated with opioids. Further studies are needed to better explain this racial difference and define its effect on patient outcomes.     

Sleep disturbances and their correlates in elderly Japanese American men residing in Hawaii

BACKGROUND: Elderly people frequently report the presence of chronically disturbed sleep. However, most data are derived from predominantly Caucasian populations. The current study is an investigation of the prevalence and correlates of sleep disturbances in a cohort of elderly Japanese American men residing in Hawaii. The importance of this population lies in its representation of an ethnic group living in a culture different from their ancestry. METHODS: This study is a cross-sectional cohort analysis of data pertaining to sleep disturbances and their potential correlates from 3,845 elderly Japanese American men residing in Hawaii (mean age. 78 years; range, 71-93 years) who participated in the fourth survey of the Honolulu Heart Program (1991-1994), which is the baseline exam for the Honolulu-Asia Aging Study. Information collected included an extensive survey of medication use, medical history, and assessments of physical and mental function, quality of life, and sleep. RESULTS: The prevalence of insomnia (DIMS) was 32.6%, a rate similar to that reported in predominantly Caucasian populations. Depression, benzodiazepine use, and several chronic health problems were the most important factors associated with DIMS. In contrast, excessive daytime sleepiness (EDS) had a prevalence of 8.9%, a rate lower than that found in elderly Caucasian populations but close to that reported among native Japanese. Important factors related to EDS were symptoms of nocturnal respiratory disturbance, depression, perception of adverse quality of life, Parkinson's disease, and digitalis use. CONCLUSIONS: Elderly Japanese men are less likely than elderly Caucasian men to report excessive daytime sleepiness. However, their insomnia rates are similar.     

Racially related health disparities and alcoholism treatment outcomes

Published studies comparing the outcomes of black and white patients with alcohol dependence have produced mixed results. We hypothesized that among alcoholic outpatients blacks would have worse outcomes than whites. A sample of 38 blacks and 136 whites were assessed prospectively at baseline and 6-12 months using a naturalistic study design. At baseline, blacks had less education, employment, and income than whites, and they were less likely to be married. They also were more likely to have family histories of substance abuse, previous episodes of treatment, cocaine use disorders, antisocial personality disorder, and poor physical health. Between baseline and follow-up, blacks received less treatment for alcohol dependence than whites. Such differences would seem to favor worse outcomes which were not found. Blacks, however, reported more social support for sobriety than whites. They also had better rates of study retention than whites, suggestive of either higher levels of motivation or stronger alliances with the treatment center. Future studies of racial differences should include measures of social support for sobriety, motivation for treatment, and treatment alliance.     

Severity of illness and resource use differences among white and black hospitalized elderly.

BACKGROUND. Disparities between races in access to health care services continue to exist. We examined differences in illness severity, charges, and length of stay between white and black hospitalized elderly. METHODS. The study sample was 1184 elderly patients. Data using the Computerized Severity Index were collected for admission, maximum throughout the stay, and discharge. RESULTS. Blacks were admitted significantly more severely ill than whites. At discharge, 96% were severity level 1. At each severity level, blacks had significantly shorter hospitalizations and lower charges. The differences were not explained by disease, surgery, age, sex, hospital, and payer. CONCLUSIONS. Admission severity disparities may exist because of patients' decisions to seek care or provider admitting practices. We need to study whether differences in severity-adjusted resource use are due to underutilization for blacks or overutilization for whites.     

Race-ethnicity on blood pressure control after ischemic stroke: a prospective cohort study

Disparities in health care access and socioeconomic status (SES) have been associated with racial-ethnic differences in blood pressure (BP) control. We examined post-ischemic stroke BP in a multiethnic cohort with good health care access. We included all hypertensive patients (n = 2972) from a randomized quality improvement trial on secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California from 2004–2006 (QUISP). Average age 73.2 ± 12.2 years; 52% female, 66% non-Hispanic white, 14% African-American, 11% Asian, 8% Hispanic, and 1% other. Demographics, diagnoses, health care utilization, BP measurements, and medications were obtained as part of routine care. We used random effects logistic regression models to examine race as a predictor of blood pressure control (<140/90 mm Hg) at 6 months post-discharge, adjusted for SES, age, gender, dementia, antihypertensive therapy, and attendance at follow-up visits. At 6 months, BP was controlled in 52.7% of blacks compared to 61.4% of whites (OR = 0.63, 95% CI, 0.48–0.82, P = .001). Black race remained independently associated with poorer BP control in adjusted analysis, although blacks were as likely to attend post-discharge visits, and more likely to be on any antihypertensive therapy than whites. Greater difficulty in controlling BP and lifestyle differences may account for this difference.     

Impact of race on treatment response and cardiovascular disease among hypertensives

To determine the effect of race on cardiovascular disease occurrence among treated hypertensive patients, the experience of 1,807 black and 2,962 white hypertensive patients who entered a union/management--sponsored, worksite-based treatment program (1973-1985), was evaluated. Participants had similar socioeconomic profiles, equal access to health benefits, and received standard treatment. Median duration of observation was 42 months. Blacks had 48, and whites 129, of the 177 morbid (strokes and heart attacks) or mortal cardiovascular disease outcomes. At baseline, blacks had more electrocardiographic abnormalities (32% vs. 19%, p less than 0.0001), lower mean cholesterol (218 vs. 230 mg%, p less than 0.001), smoked more (35% vs. 30%, p less than 0.001), and were less likely to be treated for hypertension before entering the program (53% vs. 58%, p less than 0.01) than whites. They were also more likely than whites to belong to unions employing less skilled workers (p less than 0.0001). Overall, all-cause mortality rates between the races were similar. However, total cardiovascular disease morbidity and mortality rates were 10.5 (whites) and 6.4 (blacks) per 1,000 person years (p less than 0.005); the difference was largely explained by higher myocardial infarction rates among older (55 years or older) white men (15.6 vs. 7.5, p less than 0.05). That advantage was not present amongst younger black persons. In fact, blacks lost more years of life before age 65 (102 vs. 64 years/1,000 persons, p less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of acute coronary syndromes among elderly African Americans,elderly whites,and elderly patients of other races

The purpose of this study was to investigate acute coronary syndromes (ACS) in elderly persons of different races. A prospective study was performed in which 177 consecutive unselected patients aged > or = 70 years hospitalized for ACS had coronary angiography. The patients included 11 blacks, 140 whites, and 26 patients of other races. Obstructive coronary artery disease (CAD) was present in 8 of 11 blacks (73%), 121 of 140 whites (86%), and 25 of 26 patients of other races (96%) (P < 0.05 comparing black patients with those of other races). Left main CAD was present in 0 of 11 blacks (0%), 9 of 140 whites (6%), and in 1 of 26 patients of other races (4%) (P not significant). Left anterior descending or diagonal CAD was present in 4 of 11 blacks (36%), 96 of 140 whites (67%), and 18 of 26 patients of other races (69%) (P < 0.05 comparing blacks with whites). Left circumflex or obtuse marginal disease was present in 5 of 11 blacks (45%), 72 of 140 whites (51%), and in 17 of 26 patients of other races (65%) (P not significant). Right CAD was present in 5 of 11 blacks (45%), 81 of 140 whites (58%), and 18 of 26 patients of other races (69%) (P not significant). Coronary revascularization was performed in 7 of 11 blacks (64%), 72 of 140 whites (52%), and 17 of 26 patients of other races (66%) (P not significant).     

Congestive heart failure, coronary events and atherothrombotic brain infarction in elderly blacks and whites with systemic hypertension and with and without echocardiographic and electrocardiographic evidence of left ventricular hypertrophy.

Hypertension was present in 50% of 196 blacks and in 36% of 382 whites (p less than 0.001). A prospective study of 84 elderly blacks (70% women) and 326 elderly whites (73% women) with hypertension correlated echocardiographic and electrocardiographic left ventricular (LV) hypertrophy with incidences of congestive heart failure (CHF), coronary events and atherothrombotic brain infarction (ABI). Echocardiographic LV hypertrophy (p less than 0.02) and concentric LV hypertrophy (p less than 0.001) were more prevalent in hypertensive blacks than in hypertensive whites. Hypertensive blacks were younger (78 +/- 9 years) than hypertensive whites (82 +/- 7 years) (p less than 0.001). Other coronary risk factors were similar, except for higher serum triglycerides in whites than in blacks (p less than 0.02). Follow-up was 37 +/- 18 months in blacks and 43 +/- 18 months in whites (p less than 0.01). Incidences of CHF and coronary events were not significantly different in blacks and whites. ABI incidence was 38% in blacks and 21% in whites (p less than 0.005). Multiple logistic regression analysis showed that prior CHF (p = 0.000), concentric LV hypertrophy (p = 0.018) and echocardiographic LV hypertrophy (p = 0.022) were independent risk factors for CHF. Echocardiographic LV hypertrophy (p = 0.001), serum total cholesterol (p = 0.002), concentric LV hypertrophy (p = 0.005) and prior coronary artery disease (p = 0.042) were independent risk factors for coronary events. Prior ABI (p = 0.001), echocardiographic LV hypertrophy (p = 0.001) and electrocardiographic LV hypertrophy (p = 0.034) were independent risk factors for ABI.     

Percutaneous coronary revascularization in elderly patients: impact on functional status and quality of life

BACKGROUND: Percutaneous coronary intervention (PCI) is frequently performed in elderly patients, but little is known about its impact on overall health and quality of life. OBJECTIVE: To examine changes in health-related quality of life among elderly patients after PCI. Design: Observational study. SETTING: 75 U.S. hospitals. PATIENTS: Participants in two clinical trials of PCI. MEASUREMENTS: Health-related quality of life was assessed by using the Medical Outcomes Study Short Form (SF-36) survey and the Seattle Angina Questionnaire at baseline, 6 months, and 1 year. RESULTS: Serial data on health-related quality of life were available for 295 elderly (> or =70 years) and 1150 nonelderly (<70 years) patients. At 6 months, physical health had improved in 51% of elderly patients and mental health had improved in 29%. Cardiovascular-specific health status had improved in 58% to 75% of elderly patients. Improvement did not significantly differ between elderly and non-elderly patients at 6 months or 1 year. CONCLUSIONS: Elderly patients selected for participation in a trial of PCI had substantial improvements in health-related quality of life after PCI that were similar to those in younger patients.     

Blood pressure control in Hispanics in the antihypertensive and lipid-lowering treatment to prevent heart attack trial

Historically, blood pressure control in Hispanics has been considerably less than that of non-Hispanic whites and blacks. We compared determinants of blood pressure control among Hispanic white, Hispanic black, non-Hispanic white, and non-Hispanic black participants (N=32 642) during follow-up in a randomized, practice-based, active-controlled trial. Hispanic blacks and whites represented 3% and 16% of the cohort, respectively; 33% were non-Hispanic black and 48% were non-Hispanic white. Hispanics were less likely to be controlled (<140/90 mm Hg) at enrollment, but within 6 to 12 months of follow-up, Hispanics had a greater proportion <140/90 mm Hg compared with non-Hispanics. At 4 years of follow-up, blood pressure was controlled in 72% of Hispanic whites, 69% of Hispanic blacks, 67% of non-Hispanic whites, and 59% of non-Hispanic blacks. Compared with non-Hispanic whites, Hispanic whites had a 20% greater odds of achieving BP control by 2 years of follow-up (odds ratio: 1.20; 95% CI: 1.10 to 1.31) after controlling for demographic variables and comorbidities, Hispanic blacks had a similar odds of achieving BP control (odds ratio: 1.04; 95% CI: 0.86 to 1.25), and non-Hispanic blacks had a 27% lower odds (odds ratio: 0.73; 95% CI: 0.69 to 0.78). We conclude that in all patients high levels of blood pressure control can be achieved with commonly available medications and that Hispanic ethnicity is not associated with inferior control in the setting of a clinical trial in which hypertensive patients had equal access to medical care, and medication was provided at no cost.     

How to manage elderly patients with chronic renal failure: conservative management versus dialysis

Over the past decade the number of elderly patients reaching end-stage renal disease has more than doubled. A fundamental medical decision that nephrologists commonly have to make is when to start dialytic treatment in elderly patients. Evidence is needed to inform about decision-making for or against dialysis, in particular in those patients frequently affected by multiple comorbidities for which dialysis may not increase survival. In fact, this decision affects quality of life, incurs significant financial costs, and finally mandates use of precious dialysis resources. The negative consequence of initiating dialysis in this group of patients can be deleterious as elderly people are sensitive to lifestyle changes. Furthermore, among dialysis patients, the elderly suffer the highest overall hospitalization and complication rates and most truncated life expectancy on dialysis of any age group. Studies of the factors that affect outcomes in elderly patients on dialysis, or the possibility in postponing in a safe way the start of a dialytic treatment, were lacking until recent years. Recently in the literature, papers have been published that address these questions: the effects of dialysis on morbidity and mortality in elderly patients and the use of a supplemented very low protein diet (sVLPD) in postponing the start of dialysis in elderly. The first study demonstrated that, although dialysis is generally associated with longer survival in patients aged >75 years, those with multiple comorbidities, ischemic heart disease in particular, do not survive longer than those treated conservatively. The second one is a randomized controlled study that compared a sVLPD with dialysis in 112 non-diabetic patients aged >70 years. Survival was not different between the two groups and the number of hospitalizations and days spent in hospital were significantly lower in those on a sVLPD. These studies add to the limited evidence that is currently available to inform elderly patients, their carers and their physicians about the risk and the benefit of dialysis.