The clinical status and survival in elderly dialysis: example of the oldest region of France.

BACKGROUND: The number of elderly (≥75 years) patients with end-stage renal disease (ESRD) has increased markedly, including in the Limousin region, which has the oldest population in France. We retrospectively compared outcomes in elderly and non-elderly ESRD patients who started dialysis during two time periods. METHODS: Baseline clinical characteristics, care, and survival rates were assessed in 557 ESRD patients aged ≥75 and <75 years who started dialysis in 2002-2004 and 2005-2007. Survival curves and Cox proportional hazards model were used to assess survival and factors associated with survival. RESULTS: Of the 557 patients, 343 and 214 were <75 years and ≥75 years, respectively. Dialysis was started in 2002-2004 and 2005-2007 by 197 and 146 patients <75 years, respectively, and by 96 and 118 patients ≥75 years, respectively. Median age (73.4 years [interquartile range [IQR] 61.7-79.5 years] vs 69.5 years [IQR 57.4-77.4 years] p = 0.001) and the proportion aged ≥75 years (44.7% vs 32.8%, p = 0.004) were significantly higher in 2005-2007 than in 2002-2004. Improved initial status during 2005-2007 was observed only in patients ≥75 years, with a decrease in some co-morbidities, improved walking and better preparation for dialysis. Mortality rates were significantly lower in 2005-2007 than in 2002-2004 (hazard ratio 0.81, 95% confidence interval 0.69-0.95; p = 0.008), with the difference due to factors associated with clinical status and care. CONCLUSIONS: Improved initial clinical status and better preparation for dialysis, accompanied by increased survival, were observed for patients ≥75 years who started dialysis more recently, perhaps because of early referral to a nephrologist.

Irinotecan-based chemotherapy in a metastatic colorectal cancer patient under haemodialysis for chronic renal dysfunction: two cases considered.

The pharmacokinetics of irinotecan and its metabolites has been widely studied. No pharmacokinetic data, however, are available in haemodialysis patients. We report two clinical cases of severe toxicity, one of which was fatal, in two haemodialysis patients treated with irinotecan for a metastatic colorectal cancer. In case no. 1, M.S., aged 71 years, was treated with first-line FOLFIRI chemotherapy (irinotecan 180 mg/m) for local recurrence with liver metastases of a colon cancer treated with an LV5FU2 protocol as an adjuvant therapy 3 years previously. After the first cycle of irinotecan, the patient presented grade 4 diarrhoea on day 9, then a febrile grade 4 neutropenia on day 14 leading to his death on day 18. In case no. 2, M.D., aged 57 years, was treated successively by radiochemotherapy with an LV5FU2 regimen, then with four cycles of FOLFIRI (irinotecan at 125 mg/m) and finally with the cetuximab/irinotecan combination using the conventional dosage. Febrile neutropenia was observed on day 10 of the first irinotecan infusion with a dose of 180 mg/m and on day 8 of the second infusion with a lower dose of 120 mg/m. The patient's general condition progressively deteriorated with the advancement of the neoplastic disease, which led ultimately to his death. In this patient, plasma concentrations of irinotecan and its metabolite, SN-38, were measured during the course of the first FOLFIRI cycle on day 2 and on day 4, before and after dialysis sessions. The observed results suggest that, although irinotecan is partially dialysable, SN-38 is not. In conclusion, dose recommendations have to be defined in haemodialysis patients with renal dysfunction owing to the potential toxicity of irinotecan in these patients. Special care should be taken in liver metastasis cases owing to the nondialysability of SN-38.