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Background: At least 40% of those starting onto renal dialysis at the present time are aged over 65 years old. With old age comes increased comorbidity and decreased functional status. The long term management of older patients is limited by the need for rehabilitation and by placement concerns. We describe a 5-year experience of a pilot program, created in 1991 on the recommendation of the Metropolitan Toronto District Health Council, to rehabilitate and care for elderly and disabled patients on either hemodialysis or peritoneal dialysis., Methods and Results: This retrospective, observational study reports on a total of 185 patients admitted over a 5-year period to the Riverdale Chronic Dialysis Unit for chronic care or rehabilitation. The mean age of patients admitted was 67 years (quartiles 61 and 75 years). Eighty-five percent of patients had 2 or more severe comorbidities, while 60% had 3 or more active medical issues. The most commonly used dialysis modality was hemodialysis (80%). Of the 185 patients followed 34% were discharged home, 35% died and 13% were still resident at the time of completion of the study. The most common acute medical problems seen in these patients related to their vascular access and necessitated temporary transfer to an acute nephrology center. A total of 4.7 transfers were recorded for each patient-year of follow up., Conclusions: This study describes the adaptation of facilities already present in our area, to allow better management and placement of older dialysis patients. Transfer of patients from a high level acute care facility to a chronic care facility makes economic and practical sense and may allow better long term health care planning as well as more stability for the family or care-givers.

Objective: To investigate the cost and quality of life associated with the first specialized chronic care facility for disabled dialysis patients., Design: A case controlled study in dialysis patients admitted to a specialized chronic dialysis unit (RCDU)., Setting: The study compares the cost of care in a specialized chronic care facility with that of a tertiary hospital., Patients: All dialysis patients with severe chronic disability, resident in Greater Toronto, who were unable to be discharged into the community and who were admitted to the RCDU in the first year of the program., Interventions: Chronic care and rehabilitation services in a specialized dialysis unit., Outcome Measures: Costs are expressed as $Cdn per patient year. Quality of life scores were measured using SIP and SF-36 questionnaires., Results: The data show a saving of $37,022 Cdn over the 618 day study period with care in the RCDU compared with that of a tertiary hospital. Quality of life measures show no difference in scores., Conclusions: We conclude that this preliminary report confirms a cost benefit of a specialized chronic care dialysis unit.

Clinical information was collected on 118 adolescents who developed ESRF at age 143 months or older and were treated between 1966 and 1986 at the Toronto Hospital for Sick Children. The cumulative survival rate in transplanted patients (N = 109) was 80.1% after 15 years. Survival rates after four years were 93.9% in transplanted and 46.9% in nontransplanted patients (P less than 0.001). No patient receiving dialysis alone (N = 9) was followed longer than four years. Nine patients received three transplants and had an 89% survival rate. Six of these had a functioning graft at end of the follow-up. The cumulative survival of the entire group was 76.4% at eighteen years. Forty-two (35.6%) patients had a height below the third percentile. Functional status obtained by a structure telephone interview with a member of the present treating nephrology service was good (G) or excellent (E) for 66.7% of all patients (73.5% of transplant patients (N = 68) and 45% of dialysis patients (N = 20). Hemodialysis patients functioned less well [25% G/E (N = 12)] than peritoneal dialysis patients [75% G/E (N = 8)]. Most patients achieved an appropriate level of formal education although more slowly than normal adolescents. Only 11 patients were neither enrolled in an educational institution nor employed. We conclude that aggressive treatment for adolescents with ESRF is an appropriate application of health care resources.