Dialysis can prolong life for older patients. But only slightly.

Even before Georgia Outlaw met her recent nephrologist, she had made a decision: Even though her kidneys were failing, she didn’t want to go on dialysis.

Ms. Outlaw, 77, a retired social worker and pastor from Williamston, N.C., knew many relatives and friends with advanced kidney disease, and she had seen them drive three times a week, month after month, to dialysis centers to spend hours flushing waste and excess fluid from their blood.

“They would come home faint and tired and go to bed,” she said. “That’s the day they feel normal, and then it’s time to go back on dialysis. I didn’t want that kind of pattern.”

She told her doctors, “I am not going to spend my days undergoing some procedure that is not going to prolong my life or aid me in any way.”

Ms. Outlaw was wrong about one thing: dialysis can prolong the lives of kidney failure patients. But new study Published in the journal Annals of Internal Medicine, they analyzed data from a simulated study of more than 20,000 elderly patients (average age: about 78) in the Veterans Health Administration system. They found that their escalate in survival was “modest.”

How modest? Over three years, older kidney failure patients who started dialysis right away lived an average of 770 days—just 77 days longer than those who never started it.

“I think people would find that surprising,” said Dr. Manjula Tamura, a Stanford nephrologist and researcher and senior author of the study. “They would expect a bigger difference.”

Moreover, these patients spent less time at home; they stayed in the hospital, nursing home or rehabilitation center about 15 days longer than those who never started dialysis.

Another group did not start dialysis early but continued with “medical treatment” (which could aid relieve symptoms if needed), although half of them started dialysis at some point later. They lived about as long as those who started dialysis right away.

“Our field is really debating the role of dialysis in patients who develop kidney disease in their aging years,” Dr. Tamura said. “It’s a lifelong therapy and a major lifestyle change. It can prolong life, but there are tradeoffs.”

According to data, approximately one third of the population over the age of 65 suffers from chronic kidney disease. American Renal Data SystemThe pros and cons of treatment stack up differently for them than for younger patients.

Among the elderly who develop kidney failure, most also have diabetes, and many have heart failure, lung disease or other solemn chronic diseases. They may not be candidates for transplant, the only cure for kidney failure, because they are too ailing or faint for surgery or because the wait for donor kidneys can be years.

About 13 percent of kidney failure patients who enroll in the Renal Data System begin peritoneal dialysis at home, a more common treatment in other countries but one that is gaining popularity in the United States thanks to Medicare incentives for providers. It involves filtering blood through the lining of the abdomen.

But the extensive majority, almost 84 percent in 2021continue to exploit dialysis centers despite the challenges of transportation and the significant amount of time it takes to undergo treatment.

Hemodialysis, a treatment offered in centers, requires a catheter, graft or shunt to access the patient’s blood vessels and can cause side effects like infections, fatigue and itching. And as recent research suggests, dialysis often means more time spent in health care facilities, where most older people don’t want to be.

The alternative to dialysis comes under different names – medical treatment, conservative kidney treatment, supportive kidney careIn this scenario, nephrologists monitor their patients’ health, educate them about behavioral approaches, prescribe antiemetics such as Zofran and diuretics such as Lasix to reduce fluid retention, and adjust dosages as needed.

For example, Ms. Outlaw takes diuretics, two blood pressure medications and a phosphate binder, as well as iron and calcium. Five years after being diagnosed with kidney failure, she feels good, although she is sometimes a little faint or tired, she said. She still preaches once a month at Manifestation Church of Holiness in neighboring Greenville.

Not everyone in conservative care remains so dynamic. “Some of my other patients are in wheelchairs,” said Dr. Rasheeda Hall, a geriatric nephrologist who provides conservative care to Ms. Outlaw and others at the Durham VA Health Care System.

“They are more complicated — we have to give them a lot more attention,” she said. “But they sleep in their own beds. They are not in the hospital as often. They have a better quality of life.”

Some elderly kidney patients prefer this strategy, even if death will occur several months earlier.

But often, “if you ask patients, ‘Were you given a choice?’ many of them will say no,” Dr. Tamura says.

Dialysis “is definitely still the default,” Dr. Hall said. When she sees older patients, “I say, ‘You know, dialysis is not the only thing—there are medications that we have in our arsenal that can aid,’” she said. “And they say, ‘Oh.’”

That answer seems to be common. University of Washington researchers have developed a “decision aid”—a booklet explaining conservative kidney care and its pros and cons—and I tried it on patients Age 75 and older with advanced kidney disease and their families. Objective: To encourage discussion of conservative treatment with a healthcare professional.

In the groups that received the brochure, about a quarter of patients and their relatives had such discussions. But among those who did not receive the brochure, only 3 percent of patients had discussed conservative treatment with their doctor, and none of their family members had done so.

“I was very pleased” with the results, said Dr. Susan Wong, a nephrologist and the study’s lead author. “It can be intimidating for patients to navigate alternatives when a provider is pushing, recommending or positioning dialysis as the only right thing to do.”

At her clinic, she said, about one-third of patients go to a dialysis center, one-third start dialysis at home and one-third opt for conservative treatment without dialysis.

Practices among patients with kidney disease are undergoing some changes and their physicians. The latest statistics from the Renal Data System show, for example, that the exploit of home peritoneal dialysis more than doubled between 2008 and 2021; the percentage of patients going to dialysis centers has declined.

“A few things in the kidney world seem to be improving,” said Dr. Kevin Abbott, program director in the division of renal, urinary and hematologic diseases at the National Institute of Diabetes, Digestive and Kidney Diseases.

The percentage of older Americans with kidney disease has declined, partly reflecting the wider exploit of more effective blood pressure medications in recent decades, he said. Fresh diabetes drugs that aid lower weight and blood sugar levels also show promise in treating kidney disease.

Yet, it is often up to patients and their families to consider whether to start dialysis, ask about other options, such as conservative kidney care, and weigh their choices.

If they wait for healthcare professionals to inform them about alternatives, they may have to wait a while.

Ms. Outlaw’s decision was largely based on her spiritual beliefs. “I’ve had a good life and I still enjoy it,” she said. But “if I die, I know where I’m going. My relationship with the Lord is good.”

Like any kidney patient, she could always change her mind about treatment. But she insisted she wouldn’t. “You’re taking care of me,” she said. “Dialysis is not in my future at all.”