BACKGROUND: The number of elderly patients reaching end-stage renal disease is increasing over time. This subset of patients  and  their  families,  as  well  as  nephrologists  and  other physicians, have to make a difficult decision whether or  not  to  start  dialysis.  Hence,  evidences  are  needed  to  guide  them  in  their  decision-making  for  or  against dialysis, especially in those patients affected by multiple comorbidities for which dialysis may not increase survival or may not improve the quality of life.
METHODS: Medline,  PubMed,  EMBASE  and  Cochrane Library were searched for records in English from the year 2004  to  2014  using  the  following  terms:  End-stage  Renal Disease, Dialysis, Conservative Management and Elderly.Bibliographies  of  included  articles  were  also  reviewed.All  studies  identified  during  the  database  search  were assessed  for  relevance  to  the  review  based  on  the information provided in the title and abstract. Full copies of  the  articles  were  retrieved  for  all  the  studies  that  met  the inclusion criteria. Data from all the chosen articles were then  carefully  appraised  to  come  up  with  a  descriptive  analysis.
RESULTS:Seven  studies  were  included  in  this  systematic review.  In  studies  on  survival  rates,  it  was  found  that dialysis  prolongs  survival  in  the  elderly  more  than that of the conservative management with a median survival of 39.5 months versus 18.9 months, respectively. However, it was observed that there is no significant difference in the survival  rates  between  the  two  treatment  modalities  in  patients who have multiple comorbid conditions. In terms of quality of life, there is no statistically significant difference between  the  two  groups.  However,  patients  who  chose dialysis  have  lower  satisfaction  with  life  scale  score  and patients who opted for conservative management scored higher  in  terms  of  mental  health  and  social  functioning as  compared  to  those  who  chose  dialysis.  Moreover,  patients  managed  with  conservative  management have less hospitalization rates and they most likely die at home or  in  a  hospice.  Thus,  while  patients  may  live longer  with dialysis, they can expect to spend a significant proportion of that time in a medical setting. Patients and their families differ at how they prioritize between prolonging life versus maximizing  time  at  home  and  these  preferences are important to elicit when discussing dialysis initiation.
CONCLUSION: In  patients  70  years  and  above  with  end-stage  renal  disease,dialysis offers a higher survival  rate over  conservative  management.  However,  the  survival advantage  of  dialysis  is  substantially  reduced  by  the  number of comorbid conditions most especially ischemic heart  disease.  Furthermore,  in  this  subset  of  patients, those who chose to maximize conservative management maintained quality of life comparable with those patients on long-term  dialysis  but  with  more  hospital-free days and  higher  life  satisfaction.These findings show that conservative management is a valid treatment option for selected patients.

Survival Rate ; Mental Health ; Nephrologists ; Kidney Failure, Chronic ; Life Support Care ; Myocardial Ischemia ; Hospitalization

Introduction: It is important to wean mechanically-ventilated patients as early as possible to avoid complications such as ventilator-associated pneumonia. Supplementing the diet with additional protein may help to stimulate muscle protein synthesis which may enhance respiratory muscle function and ventilator drive. This study aims to determine the effect of whey protein supplementation on the duration of mechanical ventilation in intensive care unit patients of Ospital ng Makati. Methods: We enrolled forty eligible patients in this openlabel randomized controlled trial and were assigned into two groups: Group A (N=20): patients were given enteral feeding using commercial formula with added whey protein, given as one serving every eight hours (equivalent to 18 g of additional protein per day) and Group B (N=20): patients were given enteral feeding using commercial formula alone. Weaning was started as soon as the patient fulfilled the criteria of spontaneous breathing trial and was considered successful if the patient maintained these criteria for 48 hours after extubation. Results: Our study’s results showed that the mechanically intubated patients in Group A have lesser ventilatordependent days with an average of 5.4 days as compared to those in Group B with an average of 7.45 days (p=0.00). Patients in Group A were also noted to have statistically significant higher increase in serum albumin, mid-arm circumference and triceps skin fold from baseline. Twentyfive percent of patients in Group B developed ventilator acquired pneumonia and none in Group A. No mortality was noted in both groups. Conclusion Whey protein supplementation in mechanically ventilated patients can be recommended to facilitate early weaning because of its effect on early muscle protein synthesis leading to improvement of lung function and ventilator drive. It can also help in preventing malnutrition and nosocomial infections during critical illness. With all these benefits of whey protein, its use can potentially lead to shorter duration of mechanical ventilation and hospital stay which can also mean less cost of care delivery.
Whey Proteins ; Weaning ; Respiration, Artificial ; Intensive Care Units ; Randomized Controlled Trial