Geriatric nephrology is in focus in this weeks NEJM with this excellent article by Tamura et al. By linking the USRDS database to a national registry of nursing home residents, they were able to document changes in functional status (as assessed by the MDS) before and after initiation of dialysis. The results make for grim reading:
– initiating dialysis was associated with a rapid decline in functional status in this group, such that 1 year later only 1 in 8 patients were maintaining their pre-dialysis level of function.
– the mortality rate was extraordinarily high: 50% by 9 months and 75% by one year, which makes me think that dialysis has little if any impact on survival in these patients. Both of these points are dramatically illustrated in the adjacent graph (dialysis initiation is represented by the dashed line).
This serves as a companion piece to Murtaghs classic paper, reviewed by Nate in June. It re-enforces the message that it is level of co-morbidity and functional status- and not age (mean age in this study was only 73!)- that predicts outcome in ESRD and should inform how we counsel such patients in future.
Looking at the graph, one wonders how would these patients do if dialysis is started before the MDS-ADL score started to plummet.