Author Affiliations: Division of Nephrology, Stanford University School of Medicine (Drs Kurella Tamura and Winkelmayer), and VA Palo Alto Health Care System Geriatrics Research Education and Clinical Center (Dr Kurella Tamura), Palo Alto, California. Dr Winkelmayer is also Contributing Editor, JAMA.
Ensuring access to life-sustaining maintenance dialysis therapy for individuals with irreversible kidney failure was the principle rationale for establishing the US Medicare end-stage renal disease (ESRD) entitlement in 1972. This government program, similar to the universal health care provided in other industrialized nations, removed barriers to dialysis care in the United States and undoubtedly extended the lives of millions by substantially reducing untreated ESRD due to income, race, and geography. However, with guaranteed insurance coverage for this catastrophic condition, overtreatment of ESRD with maintenance dialysis has now become evident. That is, patients with kidney failure are initiating dialysis earlier than may be necessary, and some individuals who begin maintenance dialysis may not live longer or feel better than they would have without it.1,2 Concerns about overtreatment are focused on older adults, especially those who are frail or have other severe or life-limiting conditions. However, the specter of untreated ESRD among older adults continues to be a source of unease for patients and families who are concerned that beneficial treatment is being withheld on the basis of age and cost.
Manjula Kurella Tamura, Wolfgang C. Winkelmayer. Treated and Untreated Kidney Failure in Older AdultsWhat's the Right Balance?. JAMA. 2012;307(23):2545–2546. doi:10.1001/jama.2012.6667