Side effects of dialysis in the elderly

“Doctor, what are the common side effects and complications of dialysis in an elderly patient?” The family members of elderly patients often ask me this question. Elderly patients are often skeptical to start dialysis because of their age. Dialysis in the elderly is a complex undertaking but I will try to simplify it and discuss the side effects of dialysis in elderly.

Elderly refers to people who are more than 65 years old. At this age, chronic kidney disease, mostly due to diabetes or hypertension, are diagnosed. Dialysis may be needed if the kidneys lose more than 85% of function.

Pros and cons of the dialysis in the elderly

The advantages of dialysis in the elderly are the same as the ones offered to someone younger. Dialysis allows elderly patients to lead a healthy life in spite of kidney failure. It increases life expectancy. In some patients, it may be the last resort and the only possible treatment option. Overall, quality of life can be enhanced with the help of dialysis.

On the other hand, like all medical treatments, dialysis comes with its own risks.

The common side effects of dialysis in the elderly are : 

• Low blood pressure
• Weakness
• Itching
• Muscle cramps
• Bleeding
• Infections
• Depression/anxiety
• Loss of muscle 

It is important to emphasize that not all patients will experience all the side effects. Many can be managed quite well with routine measures. It is important to have a balanced view of the pros and cons rather than keep focusing on only the side effects. 

Life expectancy by age in dialysis

The need for dialysis points to a serious underlying disease i.e kidney failure. Logically, the life expectancy of people on dialysis is lower than their healthy counterparts. 

The survival rate will depend on other factors also like patient nutrition status, any underlying conditions like cancer/heart/lung/liver diseases. Unfortunately, the elderly tend to have multiple diseases at the same time which makes it complicated to treat them. 

Patients or their relatives often ask me, “ What is my life expectancy on dialysis?” This is a question that I am somewhat reluctant to answer. That is because the answer changes from patient to patient. More importantly, patients can change their life expectancy by taking good care of their health. 

 Life expectancy depends on many factors which vary from patient to patient. Let’s consider two patients about to start dialysis with a blood creatinine level of 8mg/dl:

Mr. X is a 65 years old diabetic, who has accepted that he needs dialysis and is well prepared for it with a fistula and regular visits to his nephrologist. His hemoglobin, potassium and water levels in the body are optimal. He has recently lost appetite and is not eating well. He is admitted in a normal ward for initiating dialysis through the fistula. 

Mr.Y is also a 65 years old diabetic, but has not accepted the fact that he would one day need dialysis. He has tried various unproven treatments from quacks and has not got a fistula in his hand. His body is overloaded with water and his potassium levels are very high and hemoglobin levels are low. He is admitted in the ICU and dialysis needs to start from a dialysis catheter placed in the neck. 

As you can see, Mr.X has a better life expectancy than Mr.Y though both are of the same age and have the same illness. More than the medical care, it is the decisions/choices made by  Mr. X which resulted in a better life expectancy for him compared to Mr.Y. 

The same holds true for all elderly patients, whether they are 75 or 85 years old.

I have many patients in their late seventies and eighties who are leading a meaningful life even on dialysis. 

So my advice is not to worry about “life expectancy” but focus on what can be done to improve the quality of life of elderly patients. In fact, elderly patients and their families can improve the “life expectancy” by making the correct choices over a period of time. 

When is dialysis not recommended for the elderly?

Dialysis is not recommended for the elderly when they have multiple serious illnesses at the same time. For example : patients with cancer or heart failure along with kidney failure. In such a scenario, dialysis is not expected to improve the quality of their lives significantly. 

The ultimate aim of dialysis is to improve the quality of a person’s life. There are some situations in which dialysis may add to the problems a patient has rather than improve them. For example : an 82 year old person who also has kidney failure and  heart failure and is very frail and not able to move around. In such a person the patient and family may opt not to undergo dialysis. Only supportive care is given. This decision to forgo dialysis must never be taken without deep discussion between the patient, family and the nephrologist.

Quality of life after dialysis for elderly

In most elderly patients with kidney failure we can expect dialysis to improve the quality of life. Only in the patients with multiple other serious diseases like heart/lung/liver failure, dialysis may not be appropriate. 

Age by itself should not disqualify a person from getting dialysis. Of course, it remains an important consideration always. 

I remember talking to the daughter of one of my elderly patients coming to me and being very anxious about her father. She had read in many places that dialysis was the end of the road especially for older patients. The father was reluctant to start on dialysis as he was already 78 years old and felt that he had lived his life. 

I met the father along with the family the next day. In-fact I  felt that considering his age and kidney failure, he was not in a bad condition at all.  It was decided that we would try dialysis for a fortnight and if he felt it wasn’t helping him, we would discontinue the dialysis. 

It has been five years since then and the gentleman is 83 years old now. He attended a granddaughter’s wedding recently!

This is not just a one-off story but one I have seen repeated again and again. 

Conclusion

While dialysis in the elderly is complex, they can still lead years of a happy and meaningful life on dialysis. In the end, it depends on the diagnosis and the patient’s individual medical history. 

Age alone need not disqualify a person from getting dialysis. Discuss the details with your nephrologist to arrive at the best possible solution. I hope you found this article helpful.