Dear weenie21-ga,
Thank you for your question. First let me express my condolences
that a close family member is quite ill, from your description.
Please note, this answer is no substitute for direct medical advice,
particularly since I am unable to examine either the person you ask
about or the entire medical record.
That being said, I can give you some information. End-stage renal
disease (ESRD) is a serious condition. The rise in serum creatinine
from 4.8 to 7.1 is particularly concerning. In complete renal
failure, where the kidneys have no function at all, the serum
creatinine rises by approximately 1.0 per day. This means that the
person you describe has essentially no renal function remaining.
Although I don?t know his entire medical history, it is likely that
his renal disease is related to long-standing diabetes. One should
also carefully review this person?s medications for renal toxins (e.g.
ACE inhibitors (used for hypertension), NSAIDS ? anti-inflammatory
medications such as ibuprofen, certain antibiotics, etc.), which may
have precipitated a more acute decline in his renal function since he
has been in the hospital, particularly if he was not receiving
dialysis before.
The serum creatinine level is a marker for renal function. It is
related to muscle mass, so a ?normal? creatinine is higher for a body
builder and lower for a frail elderly person. The kidneys function to
remove waste and toxins from the blood. In impaired renal function,
these toxins and waste products rise in the blood, in parallel with
the creatinine level. This condition is referred to as uremia ? a
rise in the nitrogen-based waste products in the blood. This leads to
multiple problems which become progressively worse with time and can
lead to death. Here is a list:
* Encephalopathy ? The brain is affected by rising levels of waste
products causing changes in mental status. This can progress to coma
and death.
* Peripheral neuropathy ? This tends to happen with longer term ESRD
and causes numbness and pain in the arms and legs.
* Restless leg syndrome ? Also seen in longer term ESRD. It is
related to neuronal toxicity.
* GI symptoms - Anorexia, nausea, vomiting, diarrhea. These symptoms
can occur fairly quickly with renal failure. These symptoms may
respond to treatment with anti-emetic medication (e.g. Zofran,
Compazine, etc.)
* Skin manifestations - Dry skin, pruritus, ecchymosis. These can
also occur rather quickly.
* Fatigue, increased somnolence, failure to thrive. These are often
related to encephalopathy (see above).
* Malnutrition ? due to failure to eat generally secondary to nausea and vomiting.
* Erectile dysfunction, decreased libido, amenorrhea. Also due to
neuronal toxicity.
* Platelet dysfunction with tendency to bleeding. The patient?s
platelet level may be normal, however the platelets do not function
correctly in facilitating clotting. This is something like the
effect that aspirin has on platelets, in that the number of platelets
may be normal, however, their function is impaired. This problem can
sometimes be treated with transfusions of platelets.
* Anemia. The kidneys make a growth factor (erythropoietin) that
signals the bone marrow to make red blood cells. When the kidneys
fail, they usually (about 90% of the time) fail to make this growth
factor, leading to anemia. This can sometimes be treated with
artificial growth factor (Epogen).
More information on ESRD can be found at E-Medicine:
http://www.emedicine.com/med/topic374.htm
The field of geriatric nephrology, which deals with elderly patients
with ESRD, is a growing sub-specialty. The following article
discusses some of the issues:
Luke RG. Beck LH. Gerontologizing nephrology. Journal of the American
Society of Nephrology. 10(8):1824-7, 1999 Aug.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10446952
The Journal of the American Society of Nephrology has the full text of
this article freely available at this link:
http://www.jasn.org/cgi/content/full/10/8/1824
In terms of prognosis, the authors state that ?[w]ithdrawal of
dialysis is now the major cause of death in ESRD patients over the age
of 70.?
The best estimate on how much time one in this situation may have is
also from the above article: ?About 50% of patients die within 8 days
of cessation of dialysis; hospice treatment may be appropriate.?
Another study, which deals with octogenarians with ESRD can be found here:
The free full text article is available here:
http://www.jasn.org/cgi/content/full/14/4/1012
The article finds that the median survival for patients in their 80?s
was 8.9 months when treated conservatively (meaning without dialysis,
but using medical treatments to manage some of the problems associated
with ESRD). This means that half of the patients survived longer than
8.9 months and half survived less. Another way to put it is that
these patients had a 50% chance of surviving less than 8.9 months and
a 50% chance of surviving longer. The survival curve from this paper
can be found here:
http://www.jasn.org/content/vol14/issue4/images/large/24FF1.jpeg
On this graph, there are two lines. The solid line refers to the
survival of patients treated with dialysis. The dotted line refers to
the survival of patients treated without dialysis (?conservative?).
The vertical axis is percent of patients who survived (scaled such
that 1 = 100%). The numbers for the data are given below the graph.
More detail can be obtained from the actual article. Dialysis
extended the median survival from 8.9 months to 28.9 months. ?The 12
and 24-mo survival rates were 73.6% and 60% in patients treated by
dialysis, versus 29% and 15% for patients treated conservatively
[without dialysis].?
The authors go on to state:
?As expected, the survival of patients treated conservatively was
markedly shorter than survival of patients accepted on the dialysis
program (Figure 1). Of note, nearly 60% of deaths in the conservative
group were attributed to uremia or pulmonary edema, suggesting that
dialysis therapy, if initiated, would have prolonged life to some
unpredictable extent. In octogenarian patients accepted on the
dialysis program, median survival was 28.9 mo (95% CI, 24 to 38),
which favorably compares with the results recently reported in several
cohorts of elderly patients treated with hemodialysis or peritoneal
dialysis? Finally, the 2.4-yr life expectancy offered to our dialyzed
octogenarians represents about one quarter to one third of the life
expectancy in the general population over 80 yr of age reported by the
French National Institute of Statistics and Economic Studies INSEE. As
in other reported series, causes of death in our patients were mainly
cardiovascular in origin, but were also frequently due to malignancy
or dialysis withdrawal.?
Given this individual?s recent pneumonia, which puts further stress on
his system, and the estimates given above on prognosis, I would
recommend getting Hospice involved. I actually worked as a volunteer
in a Hospice for two years prior to attending medical school, and can
tell you that they are very good at assessing patients? suitability
for hospice. Policies vary, however, most insurance companies now
will cover hospice care for a period of approximately 2 weeks to 6
months. Most hospices prefer to take patients with approximately 2-4
weeks life expectancy.
Another option, particularly within the hospital, is to request a
Palliative Care consult. This can be useful in terms of coordinating
pain management and possible transfer to hospice. Different hospitals
obviously have different services in place and you may or may not have
easy access to these services where you are.
There is also a philosophical question to consider in terms of Hospice
and Palliative Care. These services will usually not accept patients
who are still pursuing ?aggressive treatment,? such as IV antibiotics,
dialysis, surgeries, and sometimes TPN (total parenteral nutrition ?
nutrition provided through the vein in patients who are not eating on
their own), etc. They usually have no objection to providing
intravenous hydration, since dehydration is an awful way to die. It
should be noted, however, that someone in ESRD has relatively low
fluid requirements, since he is unable to excrete excess fluid via
kidneys. Over hydration in such a patient can lead to fluid overload,
heart problems, and edema (swelling). Both Hospice and Palliative
Care services are very conscious of pain control and comfort measures
and typically manage these issues very well.
The decision to continue or terminate dialysis is of course up to the
individual you describe (or his health care proxy or next of kin) and,
depending on his overall medical condition, he may survive for a
longer period if dialysis is continued. I have seen some patients
continue with a therapy that they did not ultimately wish to continue
to survive until a significant event (a birth, a holiday, etc.), and
later discontinue therapy and ultimately die. This would of course
have to be carefully considered ? there are no guarantees.
I hope that you have found this information helpful. Please feel free
to request any clarification.
Best,
-welte-ga |
Clarification of Answer by
welte-ga
on
21 Feb 2005 06:40 PST
Dear weenie21-ga,
Believe it or not, this kind of thing happens not infrequently - one
has a set of directives for end of life care and when the situation
actually presents itself, things change. Given that your father has
very good mental status, I think that dialysis is not a bad option for
him. Often times a 90 year old comes into the hospital with a page
long list of medical problems, is unresponsive, has no meaningful
quality of life, and renal failure along with failure of multiple
other organ systems. In those situations, dialysis is only prolonging
the inevitable for no perceivable ethical purpose.
It sounds as though your father had chronic renal failure and now has
acute, complete renal failure. If this is the case, then it is not
unreasonable to hope that he may require short term dialysis to "get
over the hump," and then possibly return to his former baseline renal
function. This is similar to the problem posed by patients who may
require short-term intubation, but who have stated that they don't
want to be on a ventilator for the rest of their lives. Just as in
that situation, your father always has the option to discontinue
dialysis. His serum creatinine and electrolytes (potassium, etc.) can
be measured routinely to determine his need for dialysis over time,
with the possibility of stopping dialysis if he no longer requires it.
This again is similar to the case where someone requires short-term
intubation, e.g. to get over a pneumonia, but then fails to be
extubatable. In both cases, care can be withdrawn if that is the wish
of the patient.
I'm glad to hear that your father has a close friend running the
dialysis program. I think that makes a tremendous difference in terms
of communication and respecting your father's wishes.
In terms of the chances that short-term dialysis will work, it is
difficult to say. If your father had some renal function prior to his
hospitalization, then his chances are better than if he has gradually
fallen into complete renal failure on his own. It implies that some
acute event has possibly compromised his kidney function, and that
when this inciting factor is removed (drug, illness, etc.), then he
could possibly return to his former renal function. If not, again, he
always has the option of discontinuing dialysis at any point. As the
second study I cited mentions, dialysis prolonged life expectancy from
8.9 months to 28.9 months in patients in their 80's who presumably had
some renal function at baseline (or they would not have survived 8.9
months without dialysis). It would likely give him a chance to see
his granddaughter progress through more if not all of college,
participate in family get togethers, etc.
By the way, humor is about the only thing that gets me through the day
in the hospital, so hold on to that!
-welte-ga
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