Practical ethical issues of dialysis in the elderly.

The liberalization of acceptance criteria for dialysis and the progressive increase of the elderly population overall have increased the number of elderly dialysis patients worldwide. The main underlying diseases leading to end stage renal disease (ESRD) in the elderly patients are hypertension and diabetes, but in many patients, the cause of renal disease is unknown. The principal form of renal replacement therapy (RRT) in the elderly is hospital hemodialysis. The 1995 annual report of the US Renal Data System (USRDS) indicated that from 1986 to 1990 for patients who were older than 65 years, the two major types of vascular access were arteriovenous fistula and synthetic polytetrafluoroethylene (PTFE) graft (more than 80% of the total). The elderly on hemodialysis have a higher rate of access morbidity, and, in them, the most common hemodialysis-related complications in the elderly are hypotension, arrthythmias, and gastrointestinal bleeding. Peritoneal dialysis is the only method that permits home treatment for most elderly people, the frequency of peritonitis and catheter-related complications are similar between young and elderly patients. Incidence of malnutrition increases significantly with age; the quality of life of these patients varies according to different investigators, who described results that are lower, similar, or better than those in younger patients. Not unexpectedly, mortality is higher among the elderly dialysis patients in whom cardiovascular diseases and infections are the most common causes of death. In elderly patients, an adequate social support system, of which the family unit is the crucial component, is an important element in any form of chronic dialysis. ESRD treatment in the elderly raises many ethical issues and dilemmas. Nephrologists, citizens, politicians, and bureaucrats are concerned about the high cost of long-term therapy. Conflicts over treatment futility and rationing are inevitable. The financial restrictions on dialysis resources have had a powerful impact on patient selection; when the health care resources become limited, the elderly are the first group to be considered expendable. The most common dilemma faced by the nephrologist is the withholding and/or withdrawing of treatment from older patients.

Procollagen type-I in the serum and dialysate of continuous ambulatory peritoneal dialysis patients.

Procollagen-I carboxylterminal extension peptide (PICP) was determined in the serum and dialysate of 26 continuous ambulatory peritoneal dialysis (CAPD) patients and in the serum of 11 healthy controls. PICP serum levels were significantly higher in CAPD patients than in healthy controls (p < 0.001). There was no correlation between serum PICP levels and those of calcium, phosphorus, magnesium, alkaline phosphatase, osteocalcin, and intact parathyroid hormone (iPTH). Serum and dialysate levels of osteocalcin and iPTH showed a significant correlation (p < 0.001). The dialysate-to-serum PICP ratio in 21 patients was lower than 1.0. In the remaining 5 patients, however, the above ratio was higher than 1.0. We conclude that in CAPD patients serum PICP levels do not correlate with biochemical parameters of renal osteodystrophy. A dialysate-to-serum PICP ratio above 1.0 could implicate an increased local peritoneal fibroblastic activity and could be a useful marker of peritoneal fibrosis in CAPD.