Abstract
NSURING 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 universalhealthcareprovidedinotherindustrializednations,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 maintenancedialysishasnowbecomeevident.Thatis,patientswith kidney failure are initiating dialysis earlier than may be necessary, and some individuals who begin maintenance dialysismaynotlivelongerorfeelbetterthantheywouldhavewithout 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 forpatientsandfamilieswhoareconcernedthatbeneficialtreatment is being withheld on the basis of age and cost. Thesetensionshaveemergedatthesametimethatguidelinepanelsaredebatingoverdiagnosisofchronickidneydisease (CKD) among older adults. 3 For a given level of kidney function, older adults have a lower risk of ESRD comparedwithyoungeradults,anobservationthathasbeen attributed to less accurate estimation of kidney function, slower progression of kidney disease, and higher competingmortalityrisk.OverdiagnosisofCKDcontributestoovertreatment in the form of unnecessary referrals to nephrologists and unnecessary surgeries for dialysis vascular access among patients unlikely to progress to ESRD. 4 The counterargument is that the true risk of developing kidney failure is underestimated among older adults because patients with untreated kidney failure are not included in ESRD estimates.Theconsequencesofunderdiagnosismayrangefrom
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