A 76-year-old woman who has resided in a nursing home for two years is seen, along with her family, to discuss her medical plans. She has chronic kidney disease with an estimated glomerular filtration rate (eGFR) of 7 ml/min/1.73 m². Her other medical problems include type 2 diabetes mellitus, chronic congestive heart failure, moderate cognitive impairment, recurrent falls, a previous hip fracture, and impaired vision. She gets up in a chair for approximately 1 hour per day. She needs help with all activities of daily living except for feeding herself. She relates that she is comfortable and voices no complaints.
On examination, her BMI is 19 kg/m² and she appears frail. There is 2+ pitting pedal edema bilaterally, bibasilar fine inspiratory crackles, and a stage 2 sacral pressure ulcer.
An ultrasound of her kidneys at the time of admission to the nursing home revealed no obstruction.
Which of the following is the best management plan?

Question

Quizplus · Accepted Answer

Renal replacement therapy extends and improves the quality of life for most individuals, but it can induce or prolong suffering in others. Frail individuals with significant co-morbidity, such as this patient, may be in the latter group. One study of nursing home residents (mean age 73 and average eGFR of 10.7 ml/min) started on hemodialysis found a 58% 1-year mortality. Furthermore, these patients had limited functional status before dialysis and the health of 87% declined further after dialysis. Other studies report that unacceptable quality of life is a common reason for discontinuing chronic dialysis. Palliative/supportive care is the most appropriate option for this patient since there is a low likelihood of either hemo- or peritoneal dialysis significantly increasing quality of life (Choices A & E). (Choice B) Given that this patient is already has end-stage renal disease with a low GFR, further evaluation for reversible causes of renal failure would be low yield. (Choice C) A low protein diet, which may occasionally relieve some symptoms of uremia, is not appropriate for this frail undernourished patient. Educational objective: The risk/benefit of renal replacement therapy should be assessed in older patients and may not be indicated for selected individuals with significant co-morbidity, especially in nursing home residents. __________ References: Functional status of elderly adults before and after initiation of dialysis. (http://www.ncbi.nlm.nih.gov/pubmed/19828531) Differences between physicians in the likelihood of referral and acceptance of elderly patients for dialysis-influence of age and comorbidity. (http://www.ncbi.nlm.nih.gov/pubmed/17595178)

A 76-Year-Old Woman Who Has Resided in a Nursing Home