Dialysis vs Conservative Management for Older Adults: Manju Kurella Tamura, Susan Wong, & Maria Montez-Rath
episode
GeriPal - A Geriatrics and Palliative Medicine Podcast
47 min
3 speakers
5 chapters
transcribed 9 hours ago
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What is the decision dilemma between initiating dialysis and conservative kidney management for older adults?
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Welcome to the Jerry Pell Podcast. This is Eric Quadera. This is Alex Smith. And Alex, I am very excited today because there was an awesome article on annals on conservative management versus dialysis, kind of how we think about that. This is a topic I love to talk about. So we got a lot to cover. Who do we have with us today?
Got a lot to cover. We're delighted to welcome Susan Wong, who's a nephrologist, and she's associate professor of medicine at the University of Washington, though she's joining us from Leeds, England, where she is a distinguished Fulbright scholar. Susan, welcome to the Jerry Powell podcast.
Thank you for having me.
And we're delighted to welcome Maria Marquez Rath, who is a biostatistician and director of the Biostatistics Corps at Stanford in the division of nephrology. Maria, welcome to JerryPal.
Thank you for having me.
And we're delighted to welcome Munju Karella Tamura, who is a nephrologist and professor of medicine at Stanford. Manju, welcome to JerryPal.
Thank you, Alex and Eric. Nice to be here.
So we got a lot to cover. Again, we're gonna be talking about conservative management versus dialysis in older adults. But before we do, Susan, I think all the way from Leeds we have a song request.
Yes, maybe appropriate 'cause it's uh it's a British band, um, Let It Be from the Beatles.
Why did you choose Let It Be?
Uh to reflect uh continuing uh medical management versus starting dialysis, um, which is what uh Maria's wonderful paper goes through.
Great. Alex.
When I find myself in times of trouble, Mother Mary comes to me, speaking words of wisdom. Let it be And in my hour of darkness, she is standing right in front of me, speaking words of wisdom. Let it be Let it be let it be. Let it be let it be. Whisper words of wisdom. Let it be.
Wow.
That was impressive. We will see at the end
of the podcast if uh let it be is the appropriate uh
Well, uh I I I got I got a a lot to cover because I'm I'm really interested in the in this topic, especially around older adults, because on the inpatient side, we see this all the time. So for example, you know, we see somebody coming in from the nursing a nursing home. Maybe they have, you know, advanced CKD, not yet on dialysis. Their function's kind of decreasing. Maybe they're having some issues with cognition. And the question always is, hey, what if we like start a dialysis? Will any of that improve? And man, it feels like every year those GFR numbers just keep on ticking higher and higher when we're starting dialysis, you know, no longer in the less than tens, but maybe 15s or 16s because we're having these quasi-eureemic symptoms.
So I I wonder if I could turn to either of our nephrologists. Is what I'm seeing real? Like, are we seeing people like more older adults, more nursing home patients? Starting dialysis. And even at a higher GFR?
You want me to take this, Susan? So I think what you're describing, Eric, was probably what we saw starting about in the 2000s. There was definitely this idea in nephrology of uh what we called healthy start dialysis, um, which is this idea that we should start dialysis before someone develops really Fluorid uremic symptoms. And by doing so, we might prevent um the mortality associated with kidney failure. And so there was definitely um a practice shift towards starting dialysis at higher levels of EGFR and with less severe symptoms. Um I would say that that sort of practice has now shifted back the other way now that we have some randomized trial evidence that suggests that that actually probably does not benefit patients.
Um so I think the tide is turning, but you may not be
actually happening in real life or do we just have the evidence that it doesn't help? But Dials of centers are still dialogue.
So I think I think the tide is shifting, but Probably not enough. So just to throw some statistics out there for you, about half of patients who are over the age of 65 start dialysis with a GFR of over nine, which is sort of the level below which we, you know, have clinical trial evidence for suggesting that there may not be a benefit to starting at that level of GFR.
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Chapters
5 chapters
1
What is the decision dilemma between initiating dialysis and conservative kidney management for older adults?
0:00–5:53
2
How do early‑start dialysis practices and recent guideline shifts affect frail patients?
5:53–15:03
3
What does Manju Kurella‑Tamura’s NEJM study reveal about functional decline after dialysis initiation in nursing‑home residents?
15:03–25:57
4
How do financial incentives and for‑profit dialysis networks influence treatment choices?
25:57–47:04
5
What is a target trial emulation and how does it address immortal‑time bias in observational kidney research?
47:04–47:05
Speakers
3 identifiedMore from GeriPal - A Geriatrics and Palliative Medicine Podcast
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