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. 2009 Oct 15;361(16):1539-47.
doi: 10.1056/NEJMoa0904655.

Functional status of elderly adults before and after initiation of dialysis

Manjula Kurella Tamura  1 , Kenneth E Covinsky, Glenn M Chertow, Kristine Yaffe, C Seth Landefeld, Charles E McCulloch
Affiliations

Functional status of elderly adults before and after initiation of dialysis

Manjula Kurella Tamura et al. N Engl J Med. .

Abstract

Background: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD).

Methods: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty).

Results: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.

Conclusions: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status.

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Figures

Figure 1
Figure 1. Decline in Functional Status and Cumulative Mortality among Nursing Home Residents before and after the Initiation of Dialysis
Panel A shows the percentage of 3702 nursing home residents who underwent assessments of activities of daily living (ADL) during 3-month intervals before and after the initiation of dialysis. The cumulative mortality rates were 24% at 3 months, 41% at 6 months, 51% at 9 months, and 58% at 12 months after the initiation of dialysis. Panel B shows the distribution of Minimum Data Set–ADL (MDS–ADL) scores among nursing home residents before and after the initiation of dialysis. Higher MDS–ADL scores indicate poorer functional status. The dashed vertical line indicates the initiation of dialysis.
Figure 2
Figure 2. Change in Functional Status after Initiation of Dialysis
Data were missing for 549 nursing home residents at 3 months, 696 residents at 6 months, 823 residents at 9 months, and 787 residents at 12 months from the full analytic cohort of 3702 residents.
Figure 3
Figure 3. Smoothed Trajectory of Functional Status before and after the Initiation of Dialysis and Cumulative Mortality Rate
The dashed vertical line indicates the initiation of dialysis in a hypothetical 75-year-old nursing home resident. MDS–ADL denotes Minimum Data Set–Activities of Daily Living. The numbers on the MDS–ADL axis run from highest to lowest.
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References

    1. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007;146:177–83. - PubMed
    1. Collins AJ, Kasiske B, Herzog C, et al. Excerpts from the United States Renal Data System 2004 annual data report: atlas of end-stage renal disease in the United States. Am J Kidney Dis. 2005;45(Suppl 1):A5–A7. S1–S280. - PubMed
    1. Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol. 2003;14:1012–21. - PubMed
    1. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007;22:1955–62. - PubMed
    1. Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K. Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract. 2003;95:c40–c46. - PubMed

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