Opting Out of Dialysis Not Instant Death Sentence for Kidney Disease

Pam Harrison

March 15, 2022

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

"Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death," say Susan Wong, MD, Renal Dialysis Unit, Seattle, Washington, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: "The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care...is likely one of the consequential decisions [patients] will face."

"[But] in reality, dialysis is viewed as the default treatment for kidney failure and the option to forgo dialysis treatment is often not explicitly discussed," they add.

"We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure…and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision making," Liu and Tamura, both from the Stanford University School of Medicine, California, note.

The work by Wong and colleagues "dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients' life goals," they emphasize.

Conservative Care Assessed in 41 Studies

The review included 41 studies involving 5102 patients with a mean age ranging from 60 to 87 years conducted in the UK, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m2.

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8 to 24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

"Ten studies…provided information on the use of healthcare resources during follow-up," the researchers say. Patients generally experienced one to two hospital admissions, six to 16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was "therefore common," they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27% to 68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, "Most patients survived several years after the decision to forgo dialysis was made," they stress.

"These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management."

"Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management," they conclude.

Wong has no financial ties to industry. Tamura has reported receiving personal fees from the American Federation for Aging Research.

JAMA Netw Open. Published online March 14, 2022. Full text, Commentary

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