SINGAPORE – When someone suffers from kidney failure, the immediate reaction is he needs to either receive a transplant or go on dialysis. But these may not be the best options for everyone.

Several renal experts say that for older and frail patients, or those with ailments such as heart problems and cancer, going on dialysis might be detrimental rather than beneficial. It may not only make them sicker, but also reduce their mental capacity.

“We might have extended life by a little, but at the expense of recurrent medical issues and hospital stay, which make the final years incredibly difficult for these patients and their families,” said Dr Chua Horng Ruey, who heads nephrology, or kidney care, at the National University Hospital.

Patients on haemodialysis, where blood is taken out, cleaned and returned to the body, have a median survival rate of 6.6 years, according to the Singapore Renal Registry Annual Report 2022, released in January 2024.

Doctors say that with supportive treatment in lieu of dialysis, survival ranges from six months to three years.

Dr Chua added: “We can extend life, but we are not always able to provide the good quality of life that is desired with dialysis support.”

Patients who are very old or who have other serious medical problems, such as cardiovascular disease, heart failure, peripheral vascular disease, amputation and stroke, suffer a high death rate and recurrent hospital admissions in the short initial years of dialysis, he said.

Dr Chua said more of such patients are now opting for supportive care instead of dialysis. Those who choose not to go on dialysis are given “holistic support” that treats their symptoms and optimises their functional well-being till the end of life.

Dr Sheryl Gan, a senior consultant in renal medicine at the Singapore General Hospital, agreed, adding that for such patients, starting dialysis may not extend their lives, but would likely add to their suffering.

Dr Angeline Goh, a renal specialist who has a clinic at Mount Elizabeth Medical Centre, said: “Emerging evidence shows that dialysis initiation may be associated with accelerated rates of functional and/or cognitive decline.”

She added that it is still unclear when and how functional decline occurs in older, frail patients, but it seems to accelerate when they start dialysis.

Another renal expert, Dr Adrian Liew, whose clinic is at Mount Elizabeth Novena Specialist Centre, said dialysis for older patients with other medical problems could actually be dangerous, not just medically unsuitable.

He explained that they have a higher risk of dialysis-related infections, and those with heart or vascular diseases may develop hemodynamic instability, resulting in insufficient blood flow to the organs.

The doctors said that growing awareness that dialysis may not be the best option for everyone could be one reason for the drop in the number of kidney failure patients who had started on dialysis at the age of 80 years and older in recent years.

The renal report suggested that “possible reasons for this decline could be elderly patients passing away before their first planned dialysis or refusing dialysis”.

It added that the trends for people who have ever started dialysis “peaked for those aged 70 to 79 and then declined for those aged 80 or older, as studies have shown that dialysis offers little advantage in improving survival, especially among elderly patients with pre-existing comorbidities”.

How long people with total kidney failure can live without undergoing dialysis varies from a few weeks to about three years.

Dr Chua said survival is about two to three years from early symptoms of kidney failure, but about six months to a year if the kidney failure is full-blown.

Dr Liew said: “It depends on the state of the kidneys, age and comorbidities. In general, patients with advanced kidney failure and complications from kidney disease are looking at days to weeks of survival.”

Dr Yeo See Cheng, who heads renal medicine at Tan Tock Seng Hospital, said patients who opt not to do dialysis are managed as outpatients by a multidisciplinary team consisting of a kidney specialist, palliative care physician, medical social worker, care coordinator, dietician and pharmacist who understand and respect the patients’ care goals and wishes. 

“Many of these patients maintain their quality of life as treatment continues to address and minimise any symptoms or complications of kidney failure.”

This was exactly the reason Ms Cheok, 69, decided against dialysis. She and her sister have been running a snack stall in a primary school canteen for the past 10 years.

She was diagnosed with diabetes at the age of 55, and with moderate kidney damage about five years ago.

“My whole world crashed. When I thought about doing dialysis, I got upset. Doing it three times a week would disrupt my life. Sooner or later, I would end up not working,” said Ms Cheok, who did not want to give her full name.

She decided to “let the kidney break down” while she enjoys the rest of her life. That includes continuing with her work, as she enjoys interacting with the pupils at the school, “who are polite and friendly”. 

“I don’t want to prolong life if I’m suffering,” Ms Cheok said. Her doctor at Singapore General Hospital has given her medicine to cope with symptoms, such as swollen legs due to water retention.

Mr Ng, 80, is another kidney failure patient who has refused dialysis. His wife, who spoke for him as he is hard of hearing, said he has had friends on dialysis, and he did not like how it affected their lives.

Patients on haemodialysis usually spend three half days a week at a dialysis centre, and Mr Ng felt it was too much time spent hooked to a machine. And none of them had lived on for more than five years. The couple did not want to be named.

For Mr Ng, dialysis may not have been a good option, as he also has heart failure on top of diabetes, and high levels of cholesterol and blood pressure.

He was scared when he was told in 2023 that his kidney was failing, his wife said. But he is stoic and says 80 years is a good lifespan. He remains active, reading the papers and watching television – his favourite is Animal Planet – by reading the subtitles, and he does the cooking every day.

Mr Ng, who used to run his own engineering contractor firm, has not given up hope. He still talks about things he plans to do later this year, or even next year.