The impact of nutritional status, physical function, comorbidity and early versus late start in dialysis on quality of life in older dialysis patients.

BACKGROUND: For the majority of the older patients in dialysis, the treatment will be lifelong. Thus, quality of life (QoL) is a crucial outcome. Our aim was to assess the QoL of older Norwegian dialysis patients and to investigate the impact of early (estimated glomerular filtration rate, eGFR ≥10 mL/min) versus late (eGFR <10 mL/min) start in dialysis, comorbidity, nutritional status and physical capacity. METHODS: A self-report questionnaire including SF-36 (QoL) and the Subjective Global Assessment (SGA; nutritional status) was mailed to all patients (n = 320) ≥75 years registered in the Norwegian Renal Registry (NRR) as being in dialysis by September 2009. Reply was received from 233 patients (73%). Medical data including comorbidities and eGFR at dialysis start (obtained for 194 patients) were retrieved from the NRR. Functional capacity was determined from the SGA. RESULTS: Compared to reports from younger dialysis patients, our patients scored poorer on all SF-36 subscales. Early start in dialysis was registered for 52 patients, 142 patients started late, 51.4% were well nourished (SGA A), 32.3% moderately malnourished (SGA B) and 16.4% were severely malnourished (SGA C). No significant association between any SF-36 scores and early versus late start, nutritional status or comorbidity was found. Better physical function was significantly associated with better scores on all SF-36 scales. CONCLUSIONS: Our results indicate that physical function is important to all QoL aspects. Increased focus on physical rehabilitation seems pertinent. Early start of dialysis treatment was not associated with better long term QoL scores.

Nutritional problems, overhydration and the association with quality of life in elderly dialysis patients.

PURPOSE: The aim of this pilot study was to describe the hydration and nutritional status of a cohort of elderly dialysis patients and to explore the association between these parameters and the quality of life (QoL). METHODS: All patients over 75 years of age being in chronic dialysis by January 2008 at 3 dialysis units (n=34) were asked to participate in this pilot study, 24 patients were entered. Hydration status was assessed by bioimpedance spectroscopy (BIS) and nutritional status by the subjective global assessment (SGA), BIS, anthropometric measures and biochemical parameters. Based on these assessments the patients were classified as being cachectic or not according to newly defined criteria. QoL was measured using the SF-36. RESULTS: The results showed cachexia in 6 (25%), 37.5% had a body mass index below 24, whereas according to SGA 91% were malnourished. BIS showed low lean tissue index in 46% and overhydration in 35% of the patients. Compared to non-cachectic and normohydrated, cachectic and overhydrated patients reported consistently poorer QoL. For cachectic patients, the differences were clinically significant for all SF-36. BIS was easily applicable when used before dialysis. CONCLUSIONS: The high frequency of nutritional deficits in this study calls for more attention to nutritional status in elderly dialysis patients. There is a need for a general agreement on how nutritional status should be assessed and reported, both in clinics and in research.

End-stage renal disease and recruitment to randomized trials: why is it so difficult? Results from a survey among Norwegian nephrologists.

OBJECTIVE: Recruitment is one of the most serious challenges in randomized clinical trials (RCTs), especially in the old and frail population. A Norwegian multicentre RCT targeting end-stage renal disease (ESRD) patients older than 70 years was initiated to compare the impact on quality of life of early or late start of dialysis. Owing to poor inclusion the RCT was closed. The aim of the present study was to explore possible reasons for the recruitment failure. MATERIAL AND METHODS: A questionnaire was distributed to all Norwegian nephrologists. The questionnaire presented 11 statements which cited possible reasons for not including elderly ESRD patients in the RCT in question. RESULTS: The highest rated reasons for non-inclusion were the physician's wish to decide the timing of dialysis individually and the patient's wish to postpone the start of treatment. High mean scores were also found for reasons related to workload and capacity at the dialysis unit, whereas the influence of the doctor-patient relationship and competing studies were judged not to be important. CONCLUSIONS: The results indicate that confidence in individually decided treatment and fear of losing professional autonomy make Norwegian nephrologists reluctant to include patients in RCTs. To succeed in recruitment, there seems to be a need for cultural changes as well as increased resources to meet practical challenges.