The very elderly dialysis patient: indication and discontinuation of dialysis.

1. When the current available data in the literature is summarized it becomes evident that the majority of it supports the position that it is, at least for medical reasons, not advisable to exclude patients over the age of 80 years from chronic dialysis. 2. It is correct to say that the refusal of dialysis therapy for elderly dialysis patients would lead to a not insignificant cutting of costs, although elderly patients are not as 'expensive' as younger dialysis patients. 3. The decision to exclude patients over 80 from dialysis treatment is difficult, in our opinion, to support ethically. 4. The refusal of therapy by a dialysis patient--independent of his age--can only occur with his/her consent, as long as the patient is clearly conscious of the decision. 5. Should the patient no longer be in the condition to exercise his/her autonomy, and there is no AD, the Surrogate's Court must be consulted. 6. AD can be seen as helpful, since they not only make the decisions for physicians easier, but also because they can be seen as an act of care for family members. 7. Whenever dialysis therapy is discontinued the problematic nature of so-called essential care should be carefully considered, especially if no clear position has been taken in an AD.

The elderly dialysis patient: management of the hospital stay.

Our data show that survival times in elderly patients can be achieved, which justify the strain of the therapy on the patient, the medical effort and financial expense. It is therefore not justifiable to withhold dialysis from a person who requires it on the basis of age. It is also wrong to reduce the therapeutic endeavours to a minimum and describe these then as 'kinder' to the patient. It is to be feared that such a treatment regimen leads to a shorter survival time and simultaneously to a decreased quality of life. Particularly in view of the person's advanced age, it would seem that we are obligated to treat them with the highest quality care so that the remaining time is not only extended, but is filled with life.

Significant reduction of factor D and immunosuppressive complement fragment Ba by hemofiltration.

Because of their effect on the immune response, especially in patients with chronic or acute renal failure, factor D (FD) and the immunosuppressive complement fragment Ba are substances which may be important for the immunological status. Since they cannot be eliminated by conventional Cuprophan hemodialysis because of their high molecular weight (24,000 and 33,000 D, respectively), the effect of hemofiltration (HF) on the plasma concentration of both components was tested. It was shown that plasma levels of FD can be lowered by 43.5% during an HF treatment and the plasma concentration of Ba by 30.6%. Moreover, the two substances could be detected in the hemofiltrate. Up to 75 mg FD and up to 37 mg Ba could be eliminated per treatment, depending on the plasma concentrations and the filtration volume. A convective method such as chronic HF is therefore clearly superior to diffusive methods of blood purification when substances with such a high molecular weight have to be eliminated. It has still to be established whether the elimination of FD and Ba by chronic intermittent HF results in a sustained improvement in the immunological status of patients treated in this way.

Atrial natriuretic peptide plasma levels during hemodialysis and hemofiltration in patients with end-stage renal disease.

Using a cross-over protocol we repeatedly measured the plasma levels of alpha-hANP (atrial natriuretic peptide) during one week by radio-immunoassay in eight patients with end-stage renal disease treated with chronic hemodialysis or hemofiltration. Before each hemodialysis or hemofiltration session mean plasma ANP levels (353 +/- 112, and 337 +/- 99 pg.ml-1, respectively) were significantly above normal (50 - 166 pg.ml-1). In all but one patient, the values fell significantly towards but not reaching the normal range. Plasma ANP concentrations returned to normal at the end of the treatment in only two of the eight subjects. There was a positive correlation between the increase in body weight from one treatment to the next and the plasma ANP concentration (r = +0.35, p less than 0.05). The net loss of fluid volume during each treatment did not correlate significantly with the change in plasma ANP levels. There was no difference between hemodialysis and hemofiltration. Plasma ANP measurement may be helpful in the judgement of volume status in patients with end-stage renal disease treated by hemodialysis or hemofiltration.