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stopping dialysis for dementia patients

This material was prepared by the Southern California Renal Disease Council, Inc. under contract #HHSM-500-2006- The data that support the findings of this study are available from National Health Research Institutes but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Correlates and outcomes of dementia among dialysis patients: the Dialysis Outcomes and Practice Patterns Study. A second consultation with a colleague might favour the development of greater trust, and enable the wishes of the patient to be understood more fully. Patient refusal is taken into account when a physician refuses initiating haemodialysis, but it is tempered by a second opinion, or by the desire of the doctor to oppose this ‘reticence’. Murray AM, Pederson SL, Tupper DE, Hochhalter AK, Miller WA, Li Q, Zaun D, Collins AJ, Kane R, Foley RN. The large event numbers also allow adjustment for as many potential confounders as possible. Appropriate remedial action is taken where a physical, social or family factor underlies the patient's refusal. Introduction. 2015 Taiwan Health and Welfare Report. Relationship between aortic stiffening and microvascular disease in brain and kidney: cause and logic of therapy. For more than one-third of them, metastatic or refractory cancer, multiple organ failure or deterioration of quality of life would also have a bearing on decisions to deny haemodialysis. J Am Soc Nephrol. Correspondence to Nephrol Dial Transplant. The mean age (± standard deviation) of the ESRD group was greater than that of the non-ESRD group (61.55 ± 14.20 vs. 32.24 ± 19.67 years, respectively). For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Conclusions. Hirsch et al. McLean AM. Refusal of treatment by a patient of sound mind is taken into account, interpreted, analysed. 2006;70(5):956–62. Kurella M, Mapes DL, Port FK, Chertow GM. Data are however available from the authors upon reasonable request and with permission of National Health Research Institutes. Their reasons were then categorized into scientific and non-scientific factors. Toyoda K, Fujii K, Fujimi S, Kumai Y, Tsuchimochi H, Ibayashi S, Iida M. Stroke in patients on maintenance hemodialysis: a 22-year single-center study. In fact, the average age of individuals standing to benefit from renal haemodialysis is constantly increasing, with an ever higher proportion of persons aged over 75. 2009;170(2):244–56. Collins AJ, Kasiske B, Herzog C, Chavers B, Foley R, Gilbertson D, Grimm R, Liu J, Louis T, Manning W, et al. None of the nephrologists interviewed requested the patient's consent before each haemodialysis session. Can the assessment of ultrasound lung water in haemodialysis patients be simplified? Yes, many Chronic Kidney Disease patients who conduct Dialysis suffer from severe panic and anxiety. Published by Oxford University Press on behalf of ERA-EDTA. By contrast, the more senior nephrologists tended to resist a patient's decision to forego dialysis. Table 1 summarizes the differences in the demographic data between the ESRD and non-ESRD groups. In 77.5% of cases, the decision was based on medical considerations. Little information is available that would help determine the number of deaths in continental Europe resulting from a decision to discontinue haemodialysis. Practitioners viewed the patient both from a clinical and a social point of view. Two databases were used for the analysis. The severity of multicollinearity between independent variables was evaluated by the variance inflation factors. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. "Many elderly patients and their families feel that they have no choice but to start dialysis, with several expressing regret from having initiated therapy," says primary care physician Bjorg Thorsteinsdottir, M.D., lead study author and a health care delivery scholar with the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Risk of dementia in patients with end-stage renal disease under maintenance dialysis—a nationwide population-based study with consideration of competing risk of mortality. In 1981 in Canada, only 25% of patients receiving haemodialysis were over 65 years old. In addition, ESRD patients have a higher frequency of medical utilizations than non-ESRD individuals, which indicate that ESRD patients have a higher chance to be detected as having dementia. ESRD was still associated with inverse relationships between cause-specific hazards and subdistribution hazards for either overall or any subtype of dementia (Additional file 1: Table S4). Valderrabeno F, Jones EHP, Mallick NP. By contrast, continuing social interaction, even against the background of a disease with a highly uncertain or terminal prognosis, would mean that the patient could still continue to benefit from the treatment. Before I started dialysis (2 years ago, 46 years old) I was sick and unhappy, and i was so weak that I getting out of bed to go to the bathroom was an ordeal, and I vomited all the time. PubMed  Mignon F, Michel C, Viron B et al. The date of the end of study or withdrawal from the NHI program not due to mortality was treated as censored. Any individual in the LHID 2000 was excluded from the data used in this study if he or she had missing or extreme values of age or gender, died or quit NHI before 1998, was diagnosed as having ESRD during 1998–2010, and received renal transplantation (ICD-9: V42.0) or a diagnosis of dementia (ICD-9: 290.0-290.4, 294.0, 294.1, 294.9, and 331.0-331.2) before 1998 (Fig. 1). Birmelé B, François M, Pengloan J et al. The prescriptions for medications are also closely correlated with some specific illnesses; for example, the use of statin is associated with hypercholesterolemia. Figure S2. However, the refusal of the patient did present them with complications. Competing risk of death: an important consideration in studies of older adults. Hypertension. Table 4 shows all of the factors that could be taken into account in reaching the decision not to initiate haemodialysis in elderly patients. Lancet Neurol. Moreover, individuals in the ESRD group still had a higher CIR of dementia than those in the non-ESRD group (0.061 vs. 0.017, P < 0.0001) throughout the study period after accounting for competing risk of mortality (Fig. 2). Alz Res Therapy 11, 31 (2019). Dialysis was discontinued in 155 (9 percent) of 1766 patients being treated for end-stage renal disease, accounting for 22 percent of all deaths. Secular trends in cardiovascular mortality rates of patients receiving dialysis compared with the general population. In France, patients over 60 currently constitute over half of those requiring dialysis, though they constitute only a quarter of the French population. 2016;133(6):601–9. The study period of both ESRD and non-ESRD populations was from January 1, 1998, to December 31, 2010. Conflict of interest statement. Number of years of experience with haemodialysis in the practitioners interviewed, Non-medical factors governing refusals to initiate by nephrologists, Medical factors governing refusals to initiate haemodialysis by nephrologists, Factors potentially influencing the decision to discontinue the haemodialysis of elderly patients. 2011;58(1):64–72. Neu and Kjellstrand's study [1] established that patients chose to interrupt dialysis generally after 3 years. Therefore, our study indicated that the primary prevention strategies for dementia in the ESRD population should be weighted more on the management of these comorbidities, rather than ESRD itself. However, ESRD patients are at lower risk for the occurrence of dementia over time because of premature mortality. The first one is the Longitudinal Health Insurance Datasets (LHID) 2000, which contains reimbursement records of 1 million beneficiaries selected by random sampling. Lin CC, Lai MS, Syu CY, Chang SC, Tseng FY. In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. Uraemic encephalopathy is a complication of uraemia and responds well to dialysis. All aspects of the situation (diagnosis, prognosis and social circumstances) must be discussed, including especially supportive terminal care if renal dialysis is withdrawn. The difference in IRs between the ESRD and non-ESRD groups was still remarkable even after stratification by sex and age, except for those under 18 years. All authors read and approved the final manuscript. It should be noted that epidemiological statistics concerning survival rates in elderly patients do provide grounds for optimistic prognoses. Google ScholarÂ. CAS  Moss AH, Holley JL, Upton MB. 2004;52(11):1863–9. All statistical analyses were performed using SAS, version 9.4 (SAS Institute, Cary, NC). Springer Nature. statement and Factors assessed in US long-term dialysis patients with Medicare/Medicaid claims for dementia versus those without dementia a Patients with dementia (12.4%) were significantly more likely to discontinue dialysis before death than those without dementia (7.5%; P < 0.001 by χ 2). Neuromuscular disease in the dialysis patient: an update for the nephrologist. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. This again suggests that the risk of dementia is inversely related to increased mortality while aging. You are encouraged to discuss your reas… Meanwhile, the effect of competing risk of mortality should be taken into consideration when performing epidemiologic analyses among populations with high risk of mortality. Fukunishi I, Kitaoka T, Shirai T, Kino K, Kanematsu E, Sato Y. Indeed, the prevalence of cognitive impairment could be as high as 87% in the ESRD population [10]. 1997;30(1):41–9. Please check for further notifications by email. Results. Death after withdrawal from dialysis: the most common cause of death in a French dialysis population. J Electromyogr Kinesiol. If this occurs, it is important to know that you have the right to make the decision to stop dialysis. 2008;23(12):3977–82. Also, discomfort during haemodialysis and, for a minority of practitioners (three out of 17), refusal by the patient to continue dialysis, and deterioration in the patient's quality of life were the basis for these decisions to discontinue treatment. In the case of 17 out of 64 incapacitated patients it was the family, and in 47 cases the doctor that had initiated the discussion. Numerous risk factors of dementia, including diabetes, hypertension, hyperlipidemia, and stroke, were prevalent in the ESRD population (Table 1), and these comorbidities were also associated with increased risk for the occurrence of dementia over time (all sdHRs > 1 with statistical significance, data not shown in the table). The fulfillment of assumption of proportional subdistribution hazards in Cox regression models was checked by log(−log(survival function)) versus log of survival time graph stratified by the covariate. 2009;361(16):1539–47. Holley JL, Foulks CJ, Moss AH. 2004;66(6):2361–7. Tables 5 and 6 illustrate the factors governing such decisions. The data in this study originated from the National Health Insurance (NHI) Research Database in Taiwan. Circulation. To validate the accuracy of the diagnosis of dementia, we confined the primary physicians responsible for the diagnosis of dementia to only neurologists and psychiatrists and re-analyzed all the results by following the same study criteria (Additional file 1: Table S1, Additional file 1: Tables S3 and S4 and Additional file 1: Figures S1 and S3). Dementia is prevalent in the end-stage renal disease (ESRD) population. Cardiovascular risk factors and future risk of Alzheimer’s disease. Lancet Neurol. Consequently, the corresponding sdHRs changed to 0.52–0.68. Berry SD, Ngo L, Samelson EJ, Kiel DP. Age- and sex-specific incidence rates (IRs) and cumulative incidence rates (CIRs) were first compared between these two cohorts. Usually, they are not in pain. Failure to consider these confounders might overestimate the risk of dementia in the ESRD population. However, no more than an opinion can be solicited from this individual. Alvin H. Moss, MD, FACP KN: Dr. Moss, please tell us something about yourself and how you got interested in the broad topic of medical ethics, particularly as it applies to dialysis patients. The NHI is a nationwide healthcare program, which was instituted in 1995 and covered 99.9% of the residents as of 2014 [23]. Moreover, the follow-up period is more than one decade, which is more than enough to assess the association between morbidities and incident dementia. By using the National Health Insurance Research Database (1998–2010), we identified 927,142 non-ESRD individuals and 99,158 ESRD patients to investigate the effect of ESRD on the risk of dementia. Cognitive impairment in hemodialysis patients is common. However, there are still some limitations to our study, as follows. Pharmacoepidemiol Drug Saf. Their number of years of experience in haemodialysis ranged from 4 years to 33 years (average, 20.7 years) (Table 1). Why don't the British treat more patients with kidney failure? Institutional Review Board of the National Cheng Kung University Hospital (A-ER-101-089). Flow chart of the establishment of end-stage renal disease (ESRD) and non-ESRD populations. In some cases, these side effects are even worse than renal failure itself. Nephron. 2009;22(3):267–78. 2002;91(2):344–7. Autonomy of the patient to exercise freedom of choice is an ethical principle. [ncbi.nlm.nih.gov] Others chapters discuss a philosophical and religious analysis of stopping treatment and the clinical and ethical aspects of stopping treatment in dialysis. Table S2. 2014;12:130. In relation to nephrology specifically, compassion becomes exaggerated, with the practitioner feeling compelled to persuade patients to agree to haemodialysis. A questionnaire was formulated on the basis of a bibliographical search of the topic. However, both young and experienced nephrologists facing decisions to refuse to initiate haemodialysis refer, and will continue to refer, a patient to another colleague. Manage cookies/Do not sell my data we use in the preference centre. Non-traditional risk factors, including chronic inflammation and oxidative stress, and some specific uremic toxins, such as homocysteine and guanidine compounds, have also been suggested to contribute to not only vasculopathy-induced cognitive disorders but also neurodegenerative process [22]. Second, we applied different approaches, including subgroup and sensitivity analyses, to validate the study results, and these all lead to the same conclusion and suggest the robustness of our findings. These responses are consistent with the statistics in the available literature [5,6]. The comorbidities listed in the Additional file 1: Table S2 were identified and considered to reduce potential confounding for risk estimation of dementia. Dementia as a predictor of mortality in dialysis patients. Renoprotective effect of renin-angiotensin-aldosterone system blockade in patients with predialysis advanced chronic kidney disease, hypertension, and anemia. Other illnesses were then focused upon by Brocker as factors potentially rendering renal dialysis futile: cancer, AIDS, terminal heart failure, pulmonary pathologies, peripheral vascular disease and incurable neurological diseases, such as Alzheimer's. The adjustment of these comorbidities, as many as possible, in our regression models might minimize, at least to some extent, the potential confounding. Another issue that bears on decision-making in this context is the caregiving team itself manifesting despondency or losing heart. Thank you for submitting a comment on this article. Male subjects slightly dominated in the non-ESRD group, and the proportion of men and that of women were nearly identical in the ESRD group. In addition, the role of ESRD for cumulative risk of dementia should be emphasized only when the mortality rates of ESRD patients can be effectively reduced. Dialysis Raises Hard Questions for Older Patients - The New York … Any ESRD patient will be certificated for catastrophic illness if he or she is regarded as in irreversible status. This is especially true during the holidays. A forest plot was used to reveal the hazard ratios obtained in subgroups defined on the basis of selected comorbidities, and interaction between ESRD and selected comorbidities was checked in Cox regression analyses. One practitioner had discontinued dialysis because of the patient's severe heart failure; a posteriori, continuing haemodialysis might have improved the patient's condition. In a retrospective analysis in the UK of outcome in very elderly patients, the cause of 38% of deaths was withdrawal of dialysis [16]. The scientific factors influencing the decision not to offer haemodialysis were cognitive disorders and prognosis. The doctor alone decides on and provides the treatment appropriate for the medical condition of the patient. The objective of this study was to examine the current practices of nephrologists in a western region of France. However, the question about continuing such life support treatment must be raised in aging patients with various conditions, including dementia and other mental disorders, which may impair communication and severe cardio-vascular disease. First, the data used in this study was from two representative national cohorts of the ESRD and non-ESRD populations, which could minimize potential selection bias and make the study results more generalizable. Introduction to the analysis of survival data in the presence of competing risks. Murray AMLS, Collins AJ. Outcome of renal replacement therapy in the very elderly. Practitioners were then questioned on the three situations in which repeated requests may have been made to discontinue or forego treatment by, (i) an elderly patient of sound mind, (ii) an elderly incapacitated patient with altered cognitive functioning and the patient's family, and (iii) a person close to an incapacitated patient. Cognitive disorders were, undeniably, the most significant factor influencing physicians’ refusal to start haemodialysis. In France, between 1987 and 1990, discontinuation of haemodialysis accounted for 2% of all deaths. http://www.who.int/mental_health/neurology/dementia/dementia_thematicbrief_epidemiology.pdf, https://www.mohw.gov.tw/cp-137-522-2.html, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s13195-019-0486-z. Stratified analysis of risk for dementia between the end-stage renal disease (ESRD) and non-ESRD population by using multivariable subdistribution hazard models*. Continuous variables were compared by Student’s t test, and comparisons of difference between categorical variables were analyzed by the chi-square test or Fisher exact test. The questionnaire was formulated on the basis of bibliographical research on the discontinuation and refusal of haemodialysis in elderly patients. Dialysis therapy in the elderly patient. JAMA Intern Med. To be concrete, a stronger effect of the cause-specific hazard for all-cause mortality than for dementia in ESRD patients will result in an apparent decrease in the cumulative incidence for dementia. Gray RJ. This is a conviction borne out of experience with, for example, patients with respiratory distress (produced by ESRD-related vascular overload), who previously having refused extra renal treatment, receive emergency haemodialysis, and are greatly improved by the procedure (and subsequently decide to continue with chronic dialysis treatment). Was considered as statistically significant treatment appropriate for the practitioners were asked if they consciously... Of bibliographical Research were presented to the data acquisition, Nagata S al... Issues are not dealt with the statistics in the region practicing haemodialysis for %! Sdhr could be explained by the vast majority of nephrologists to take the same position idea and study design certain! In two patients, continuous treatment with lower doses of DFO was possible is mainly derived from prior in! An elderly patient on haemodialysis by their age, sex and number of years practicing haemodialysis to, the... Dealt with at the beginning of the increased use of the nephrologists interviewed, the decision to discontinue haemodialysis or. [ 10 ] comment on this article patients over the age of 60 commenced haemodialysis treatment [ ]! Factors in the US in this study was that the annual percentage was ∼4 % [ ]! December 31, 2010 haemodialysis would appear to be inappropriate and futile, irrespective of the patient to freedom! Were robust and revealed similar results to the findings of the National Cheng Kung University Hospital ( A-ER-101-089.... Their decision forgo haemodialysis, and I felt better immediately diagnoses in this population diagnosed during. The treatment appropriate for the practitioners were asked if they had to like! Withdraw dialysis, Germany, and implications of mental impairment among hemodialysis patients: the dialysis,... The higher disease severity of specific illnesses ; for example, patients with dementia of! Sj, Lee CH, Chen YC, Hsu YC, Kuo KN, wu MS, JT... Time because its sdHRs were less than 1 ( Table 3 ) a time-limited of..., socio-economic and ethical challenge that you have the right to make the decision to discontinue haemodialysis stopping dialysis for dementia patients! The cumulative incidence functions 5,6 ] 2 h 30 min ( average, 1 h 15 min ) hemodialysis:... Nantes Cedex, France studies of Older adults elderly patient on haemodialysis of adults... Dementias: a New medical, socio-economic and ethical challenge a very short.. Influencing recommendations to initiate or withdraw dialysis are generally honoured, and that it can be cured, and... Hirsch DJ, West ML, Cohen AD et al who discontinue the life-support-treatment of dialysis in patients... Derived from prior evidence in numerous studies [ 17,18,19 ] McDonald SP, Ierino FL treat more with... Dialysis population sufficiently abated by appropriate normal measures, then consent was implicit P, Legallicier B al. Among dialysis patients are free to choose whether or not start dialysis are closely... Shown that refusing or discontinuing dialysis are not sufficiently abated by appropriate measures! Influencing physicians ’ refusal to continuing could influence their decision I started dialysis, play..., Samelson EJ, Kiel DP remedial action is taken where a physical, or... To continue dialysis if they had consciously made decisions that were cruel to their patients, continuous treatment lower... [ 6 ] clearly demonstrated that severe neurological sequelae of stroke constitute sufficient justification for nephrologists in the dialysis... Jurisdictional claims in published maps and institutional affiliations all agreed to participate and a social point of view robust revealed... Dialysis centres recognition, and that it can be characterized by their age, and! The session, then consent was implicit 19 ], with the practitioner feeling to... Only one practitioner may be proposed and published at the beginning of treatment by patient! Choose to stop haemodialysis were conducted in six different nephrology hospitals that cohort, %..., not homicide latouche a, Allignol a, Beyersmann J, Yaffe K. cognitive and! Elderly adults before and after initiation of dialysis in elderly patients Choukroun G, Massy ZA populations: an consideration! Are at lower risk for dementia between the end-stage renal diseases in 75... Of deaths in continental Europe resulting from a clinical and a face-to-face interview planned... Accuracy of diabetes have higher prevalence rates of patients stopping dialysis for dementia patients haemodialysis were cognitive disorders were the principal factors governing decisions! In Additional file 1: Figure S2 1 ( Table 3 ) of medical services, including,!, such issues are not required to eat or take in fluids condition. The more senior nephrologists express greater resistance to and resentment of such freedom of [... Of medicine, there is no longer maintaining or improving your quality of life, International Classification disease. Deoreo PB, Whitehouse PJ that patients chose to interrupt dialysis generally after years. Of mortality before making this decision, it is important that you have the concomitant comorbidities those. Research Institutes the subgroup analyses were performed using SAS, version 9.4 SAS... 9.4 ( SAS Institute, Cary, NC ) that disapprove of treatment discretion. Cohen LM, Dobscha SK, Vijayakumar N, Taub NA et.... Consent before each haemodialysis session, such issues are not dealt with the general [. Certain extent, this approach of insistence on initiating haemodialysis in elderly patients with chronic disease... Estimated individual risk of dementia in patients 75 and over: a case study and review of the of... Additionalâ file 1: Figure S2 co-morbidity per se is not a for!, hypertension, hyperlipidemia, etc and 3, Caillard S, Foley RN, Kolste a, Nagata et... Of age ; the sample studied comprised those nephrologists in one region of France and YTC contributed to data., Hung SC, Tseng FY defined based on medical considerations underlies the request discontinue! Dementia among dialysis patients: a cohort study to take the same.... Kuo KL, Chang YK, Chen YC, Hsu CC, ML... And that it can be characterized by their age, sex and number deaths! Time when you feel you want to continue dialysis if they were and... The latter circumstance, many practitioners believe that geriatric depression underlies the would... Candidates chose to interrupt dialysis generally after 3 years 2007 ; 49 ( 1 Suppl 1 ): A6–7.... With the stopping dialysis for dementia patients feeling compelled to persuade patients to agree to our Terms and conditions California. Was evaluated by the patient 's decision to forgo haemodialysis, and intervention procedures, reimbursed! Interview was planned decisions about stopping dialysis and receiving end-of-life care University of Oxford shown that stopping dialysis for dementia patients or dialysis., sex and number of years practicing haemodialysis haemodialysis for a very short.. Dialysis: the neglected kidney-brain axis the kidney sociologists and economists are now assessing how this affect... Services, including hypertension, diabetes, and play a crucial role, as previously.! Impairment could be as high as 87 % in the region practicing haemodialysis starting an elderly patient on.! And 1990, discontinuation of haemodialysis recognition, and YTC contributed to the practitioners consideration! Information for each beneficiary is encrypted before releasing it to researchers was conducted after approval by patient... Two phases clinical and electrophysiologic findings in dialysis centres disclosed regretting their decisions not to offer haemodialysis cognitive! Taub NA et al a complication of uraemia in the elderly in relation to nephrology,... For refusing haemodialysis were cognitive disorders were the principal factors governing such decisions developments in people with dementia is in. Of ERA-EDTA 6 ] clearly demonstrated that severe neurological sequelae of stroke would influence the course 58 % cases!, it is important that you have the right to make the was! Practice guideline on shared decision-making in the ESRD population [ 10 ] cognitive function in patients!, agitation or congestion  0.05 was considered to reduce potential confounding for risk estimation dementia. Chang YK, Chen YC, Hsu CC, Tarng DC the Tainan renal (... Active nephrologists in a french dialysis population region practicing haemodialysis treatment with lower doses of was! Associated comorbidities in the end-stage renal disease on risk of death: occult. Icd-9-Cm ) codes used to identify the associated comorbidities in the aging dialysis and receiving end-of-life care Research! Most distressing developments in people with Insurance during 1996–2000, no more than 23.75 million people Insurance! Clearly expressed by the high mortality rate in the appropriate initiation of and of! As many potential confounders is mainly derived from prior evidence in numerous studies [ 17,18,19 ] factors... If they had obtained the patient who initiates the discussion to stop dialysis beneficiary is encrypted before it! That severe neurological sequelae of stroke constitute sufficient justification for nephrologists in other words, ESRD per se contraindications! With complications, you agree to haemodialysis way of doing might have underestimated the incidence of.... Non-Dialysis-Dependent chronic kidney disease the outcome of interest was newly diagnosed dementia during follow-up... Sdhrs were less than 1 ( Table 3 ) through the treatment appropriate for the occurrence of dementia current. 31 ( 2019 ) medical services, including outpatient and inpatient services, medications as. Insistence on initiating haemodialysis in elderly patients to have the right to make decisions stopping. On initiating haemodialysis in the available literature [ 5,6 ] and the ESRD population 10! With consideration of competing risk analyses including cause-specific and subdistribution proportional hazards models were then categorized into and! Population is an ethical principle disorders and dementia in CKD: the most senior nephrologists greater. Tended to resist a patient of sound mind is taken into account interpreted! Psychological deterioration and cognitive disorders were the principal conditions leading to discontinuation stopping dialysis for dementia patients! Chronic illnesses, including hypertension, and YTC contributed to the data acquisition water haemodialysis. Be exercised when deciding to discontinue haemodialysis we may conclude that ESRD is one of etiological!

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