Course Authors

Eli A. Friedman, M.D., and Amy L. Friedman, M.D.

Dr. Amy Friedman is Associate Professor of Surgery and Co-Director, Division of Transplantation, Yale University, School of Medicine, New Haven, CT.

Dr. Amy Friedman reports no commercial conflict of interest. Within the past three years, Dr. Eli Friedman has received grant/research support from Alteon.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Learning Objectives

Upon completion of this Cyberounds^®, you should be able to:

• Discuss the growing importance of elderly patients with kidney failure as a medical and ethical concern

• Elucidate the etiology of ESRD in geriatric patients

• Discuss issues relating to provision of donor kidneys to geriatric patients.

 

Prejudice against treatment of older patients with irreversible kidney failure is an understandable consequence of financial stress experienced by national health agencies pressured by a growing shortage of available deceased kidneys for transplantation. Berlyne, in 1984, was provoked to decry the behavior of the United Kingdom's National Health Service in policies that effectively excluded older uremic individuals from life prolonging hemodialysis and kidney transplantation.(1)

What was discerned by Berliner's assessment of uremia therapy in the United Kingdom was the credibility of growing complaints that the "system" induced broad discrimination against the elderly in acceptance for end stage renal disease (ESRD) treatment. The mechanism of exclusion for geriatric kidney failure patients was based in referral patterns that discouraged generalists from sending their uremic patients to nephrologists, thereby permitting nephrologists to truthfully state that they accepted all referred patients. In reality, however, British nephrologists were adhering to a system that, de facto, declined to offer ESRD therapy to the elderly.

Worldwide Ageism

A worldwide barrier to acceptance of elderly ESRD patients persists today. Currently, exclusion of geriatric patients with ESRD can be surmised from international comparisons of incident and prevalent ESRD patients reported in national registries and/or recorded by the United States Renal Data Service (USRDS).

Consider America's northern neighbor, Canada. According to the most recent report (2003) of the USRDS in Chapter 12, International Comparisons, in 2001 Canada provided ESRD incident care (newly treated) at a rate of 152 per million population, while the United States started treatment at a rate of 336 per million. Three possible explanations, individually or in combination, might underlie this sharp international difference in provision of ESRD treatment:

1. ESRD is much less prevalent in Canada than the United States because of genetic, racial, or life style differences.
2. ESRD is overtreated, inappropriately, in the United States by including "futile" and older patients.
3. ESRD is undertreated, sadly, by excluding sicker and older patients, in Canada.

Prevalence counts showed the same discrepancy with a 2001 ESRD treatment rate in Canada of 841.1 per million versus 1,403 per million in the United States. Elsewhere, as tabulated by the USRDS, the World Bank, and the Central Intelligence Agency (Figure 1), there is a direct correlation between national ESRD treatment rates and Gross National Income. When fiscally driven rationing is applied, it is the elderly that are preferentially, though perhaps neither officially nor consciously, excluded.

Figure 1. Selected ESRD Rx vs. Income.

As is true for nearly all measured parameters, treatment of ESRD is a clear correlate of national wealth. Poor nations such as China and Bangladesh with an annual per capita income below $1, 000 (US) are unable to afford the treatment costs of ESRD meaning that nearly all patients with kidney failure die untreated.

Etiology of ESRD in Geriatric Patients

Inspection of the primary diagnoses listed when geriatric patients are referred for treatment of ESRD (incident cases), as reported by the USRDS,(2) underscores the extraordinary dominance of diabetes and the remarkable impact of race. As depicted in Table A-7 of the Annual Data Report for 2003, for patients age 65 or older who began treatment from 1998 to 2001, diabetes as the listed cause of renal failure in geriatric patients accounted for 74,252 (44.4 percent), hypertension accounted for 60,352 (36.0 percent), glomerulonephritis was listed for 10,756 (6.0 percent) and cystic disease of the kidney accounted for 2,099 (1.2 percent) (Figure 2).

Figure 2. Etiology of Geriatric ESRD 1999-2001.

Cause of kidney failure in incident geriatric ESRD patients age 65 and older as reported in the 2003 Annual Data Report of the USRDS.(2) Note the dominance of diabetes and hypertension.

Tabulating incident geriatric ESRD patients age 65 or older by race shows the exceptionally greater risk associated with skin pigmentation. Thus, as listed in the USRDS Annual Data Report Table A-8 for incident patients between 1998 to 2001, attack rates by race for diabetes and hypertension respectively were: whites 489 and 265 per million, African Americans 1,831 and 1,123 per million, Native Americans 2,278 and 451 per million, and Asians 960 and 418 per million. Of the four races reported, the incident rate for both diabetes and hypertension as causes of ESRD was lowest in whites.

In those initiated on ESRD therapy, death of geriatric ESRD patients age 65 or older was most likely secondary to cardiac complications. Expressed as deaths per 1,000 patient years at risk for patients age 65 or older treated from 199 to 2001, cardiac deaths occurred at a rate of 130 per 1,000, septicemia at a rate of 34.9 per 1,000, cerebrovascular disease at a rate of 16,6 per 1,000, and malignancy at a rate of 12.8 per 1,000 (USRDS Annual Data Report Table H-13).

Overall, the statistical characterization of geriatric ESRD patients mirrors that of the entire ESRD population, which is not surprising, as increasingly ESRD per se is a geriatric disease. The practicing nephrologist in the first decade of the 21st Century has per force become both a geriatrician and a diabetatologist.

Exclusion from Kidney Transplant of Elderly ESRD Patients

Spotlighting the reality that being old means denial from some medical interventions provokes the question of, "How old is too old?" The reader might test this issue by asking whether he (she) would allocate a deceased donor kidney to a uremic patient aged 95 years? Most respondents will, undoubtedly, be against such an allocation. But what if the question was rephrased and the age of the hypothetical patient reduced? Is age 85 acceptable? How about 75 or 65? Each of us would find the series of age presentations challenging, unmasking absolute yes and no responses at our own subjective limits, but would be troubled in applying a specific age exclusion. To illustrate the dilemma, examine Figure 3, a photograph taken in March, 2004, of an 88-year-old fully functioning deceased donor kidney recipient in his fifth post-transplant year, with a serum creatinine concentration of 1.8 mg/dl.

Figure 3. Elderly Renal Transplant Recipient.

Radiating robust health and joy of life, this 88-year-old renal transplant recipient is seen during a March 2004 routine follow-up clinic visit.

Would it have been prudent (ethical?) to have excluded this individual because of his advanced age of 84? In actual practice, only 9.5 percent of kidney transplants in the United States are performed in recipients who are 65 years or older (Table I). Thus, while geriatric patients age 65 and older account for 48.7 percent of incident end stage renal disease (ESRD) patients in the United States,(2) their near total exclusion from the active recipient pool bears examination.

Table 1. First Kidney Transplants Performed in 2000, by Age (Years)

Few reports detail morbidity and/or survival of elderly ESRD patients whether treated by hemodialysis, peritoneal dialysis, or a kidney transplant. As a generalization, the literature consensus is that outcome is sharply inferior to that noted in younger individuals. Defining "elderly patients" as those at least 60 years old (mean age 66.7 years) given renal replacement therapy (RRT) in Norway, Fauchald et al. compared survival on dialysis or after renal transplantation for up to four years.(3) After four years, actuarial survival was 62 percent in 122 renal allograft recipients compared with 13 percent in 119 patients treated by dialysis.

Utilizing a program termed "Old-for-old" kidney allocation in which 69 patients aged 60 or older were given kidneys from donors older than 64 years, Fritsche et al. reported an 89.5 percent patient survival and 86.9 percent graft survival at one year.(4) Annual reports from the USRDS document continuously improving kidney transplant outcomes in elderly ESRD patients (age 65 or older). For persons ages 65 and over, one year graft survival rates from 1990 to 2000, increased from 74.0 percent to 82.8 percent, while patient survival increased from 78.1 percent to 81.7 percent.(2)

Parameters of Ethical Conundrum

UNOS, the United Network for Organ Sharing, on their website (www.unos.org) on March 9, 2004, listed 59,339 persons waiting for a kidney or kidney plus pancreas transplant, noting that throughout 2003 a total of 13,857 kidney transplants were performed, of which 7,962 were from deceased donors. Imbalance between available donors and potential recipients translates into is a median waiting time of 1,472 days for waitlisted recipients age 50 and over. Confronting this stultifying delay, how should the plight of geriatric kidney patients be weighed?

Obviously, in the US, geriatric ESRD patients aged 65 years and over are less likely to receive either a deceased donor or live donor kidney transplant than are younger ESRD patients. Pressures resulting from the expanding waitlist for kidney transplants may well have induced organ allocation facilities to opt for younger over older potential recipients, even though age, per se, is not a recognized component of the donor kidney allocation system. One might surmise that elderly transplant candidates have relatively fewer contemporaries (related either through genetics or emotion) who are sufficiently healthy to meet rigorous donation criteria. Many elderly patients may also be unwilling to agree to subject their older siblings, spouses, and friends to the risks of a donor nephrectomy, preferring to await deceased donor organ availability.

It has been theorized that kidney failure in the "very old" is a "futile" state in which minimal intervention is prudent and ethical.(5) Withdrawal from maintenance hemodialysis, once initiated, in geriatric ESRD patients is common(6) and, some reason, validates the position that it was unwise to have begun such arduous therapy. Planchette describes as 'covert rationing' the adoption of acceptance policies that ration care to older persons, thereby recognizing general acceptance of the need to ration scarce resources, whether or not such a policy is actually formalized.(7)

By contrast, Cameron argues that 'there are neither medical nor ethical grounds for avoiding kidney transplantation, in those aged over 70 or even 75 years of age. He notes that death with a functioning graft (secondary to cardiovascular disease and infections) is more common in the elderly, but graft losses from rejection are lower, resulting in similar overall outcomes. Although "most elderly patients seem to have excellent functional rehabilitation after a kidney transplant," Cameron writes, "giving the precious organ to the elderly who have a shorter expected lifespan may present an ethical problem."

Rao focuses on the key restraint worrying transplant teams treating geriatric ESRD patients,(9) whether, in an era of donor kidney shortage, it is rational/ethical to permit geriatric ESRD patients to use a scarce resource?(10)

According to Jecker and Schneiderman, there are four common sources of current debates on futility and rationing: rising health care costs; high-technology medicine; aging of society; and the effort to limit patient autonomy, and they, therefore, propose fresh definitions for futility and rationing. Futility, they assert, should refer to treatment and outcome in a specific patient, while rationing occurs against a backdrop of resource scarcity.(11) In other words, the decision to declare treatment for a specific patient as futile must be independent of external pressures that force rationing.

Geriatric Kidney Failure: Illustrative Case

An 83-year-old shopkeeper known to have chronic kidney disease from autosomal dominant polycystic kidney disease (ADPCKD) deteriorates to become symptomatic with reversed diurnal sleep pattern, daily nausea, loss of muscle mass, and blotchy skin ecchymoses. His laboratory findings include: serum creatinine concentration 9.3 mg/dl (creatinine clearance 6 ml/min), hematocrit 29%, phosphorous 6.2 mg/dl, and serum albumin 3.1 g/dl. The responsible nephrologist decides that "conservative management" has run its course; in other words, one of four options in management of end-stage renal disease (ESRD) should be elected promptly (Table 2). The patient expresses a strong desire to participate in his grandson's wedding scheduled for five months hence.

Table 2. Options in Uremia Therapy.

1. Supportive care only, electing death
2. Peritoneal dialysis
3. Hemodialysis
4. Kidney transplantation

Considering practical, ethical, and socioeconomic realities, which of the following is appropriate?

1. Considering practical, ethical, and socioeconomic realities, which of the following is appropriate?
2. Peritoneal dialysis permits return to work responsibility with minimal morbidity and should be advocated as the only practical choice.
3. Maintenance hemodialysis is the only practical option as renal failure patients in the ninth decade proffer futility as an endpoint when kidney transplants are attempted. Peritoneal dialysis, because of its nearly constant complications of peritonitis and depression, affords no advantage over a hospice.
4. Purchase of a kidney from a broker in Pakistan, India, Russia, the Philippines, or Peru should be arranged to attain the fastest and most complete rehabilitation.
5. Because the wait for a deceased donor kidney can reach more than five years in some regions (New York, for example), every effort should be made to seek a familial kidney donor evaluating a 73-year-old brother, 79-year-old wife, and a 19-year-old grandson (brother and grandson screened and negative for ADPCKD).

Correct Answer: None

In this example, there is no single correct answer. Psychosocial patient evaluation is appropriate at every age group. For many geriatric patients, not opting for the intensity and life quality of long-term dialytic therapy may be the wisest choice. But each decision must be individualized and the patient should be allowed to meet with patients presently on both peritoneal and hemodialysis to judge for himself.

It is not easy to decide between peritoneal and hemodialysis. Each regimen has been successfully deployed to realize full rehabilitation in geriatric patients. Local medical skills and patient preference must be weighed against the bias of the treating nephrologist.

Participating in marketing of an organ transplant is illegal in the United States, punishable by up to five years in prison. Yet, worldwide, an estimated one-third of current kidney transplants are from financially compensated donors. Despite this reality, local kidney care providers are proscribed from any involvement in the sale of a kidney. Referring a potential recipient to an organ broker is probably illegal.

While waiting for a deceased donor kidney incurs the least "imposition" on the patient's family, waiting for years may not be an option for patients in their ninth decade. Should the patient's spouse or brother be in sound health, their donation of a kidney is consistent with contemporary practice. Accepting a donor kidney from a grandchild provokes an ethical debate that falls beyond this discourse.

Conclusion

As the population ages, the quest for equity and justice in uremia therapy for the aged may increasingly need to be confronted by clinicians, patients and society.