Abstract and Introduction
Abstract
Graphical Abstract
Background: Shared decision-making (SDM) is important when considering whether an older patient with advanced chronic kidney disease (CKD) should be managed with dialysis or conservative kidney management (CKM). Physicians may find these conversations difficult because of the relative paucity of data on patients managed without dialysis.
Methods: This prospective observational study was conducted in a unit supported by a multidisciplinary Kidney Supportive Care (KSC) programme, in a cohort of 510 patients (280 CKM and 230 dialysis) ≥65 years of age with CKD stages 4 and 5. Survival was evaluated using logistic regression and Cox proportional hazards models. Linear mixed models were utilized to assess symptoms over time.
Results: CKM patients were older (mean 84 versus 74 years; P < .001) and almost 2-fold more likely to have three or more comorbidities (P < .001). The median survival of CKM patients was lower compared with dialysis from all time points: 14 months [interquartile range (IQR) 6–32] versus 53 (IQR 28–103) from decision of treatment modality or dialysis start date (P < .001); 15 months (IQR 7–34) versus 64 (IQR 30–103) from the time the estimated glomerular filtration rate (eGFR) was ≤15 mL/min/1.73 m2 (P < .001); and 8 months (IQR 3–18) versus 49 (19–101) from eGFR ≤10 mL/min/1.73 m2. A total of 59% of CKM patients reported an improvement in symptoms by their third KSC clinic visit (P < .001). The rate of unplanned hospitalization was 2-fold higher in the dialysis cohort.
Conclusions: CKM patients survive a median of 14 months from the time of modality choice and have a lower rate of hospitalization than dialysis patients. Although the symptom burden in advanced CKD is high, most elderly CKM patients managed through an integrated KSC programme and can achieve improvement in their symptoms over time. These data might help with SDM.
Introduction
The incidence and prevalence of older patients receiving dialysis have continued to increase. In 2020, the highest prevalent population of patients receiving dialysis in Australia was the 75- to 84-year-old age group, with >3000 patients per million population.[1] The incidence of dialysis in patients ≥85 years of age has also continued to increase over the last few years.[2] Reasons for this are multifactorial, including an ageing population with increased life expectancy and more relaxed criteria for considering a patient for dialysis.[3,4] However, mortality for older dialysis patients remains high,[5] many regret the decision to dialyse[6,7] and withdrawal from dialysis is the leading cause of death, at least in Australia.[5] Furthermore, the heavy symptom burden of patients with end-stage kidney disease (ESKD) increases toward the end of life and is not necessarily alleviated by dialysis.[8–10]
Therefore, discussions regarding the appropriateness of dialysis compared with non-dialytic conservative kidney management (CKM) in an older patient are often complex. The Renal Physicians Association guidelines recommend shared decision-making (SDM) involving the nephrologist, patient and caregivers.[11] When patients actively engage in SDM they have greater treatment satisfaction.[12] Many older patients are not aware that dialysis initiation is voluntary, and not being engaged in decision-making is associated with poor treatment satisfaction.[12]
However, nephrologists often find this process challenging given the relative paucity of data available for these SDM discussions regarding the survival, symptom burden, hospitalization rates and illness trajectory of ESKD patients on a non-dialytic pathway.[13] Emerging literature suggests that survival advantages of dialysis may be lost in the very old or highly comorbid patients.[14–16] Dialysis patients also have a higher number of days spent in hospital, including intensive care stays,[17,18] and qualitative studies suggest that many patients may choose quality of life over quantity.[19]
Kidney Supportive Care (KSC) is a growing discipline that integrates nephrology and palliative care for patients with advanced chronic kidney disease (CKD), with a focus on SDM, optimizing quality of life, addressing symptom burden and conducting advance care planning to ensure goal-concordant care at the end of life. Existing studies that are used to guide SDM mostly come from units where there is no structured or formalized KSC programme. We have had such a programme since 2009 and reported our initial findings on the outcome of CKM patients in 2015.[20] This study builds upon that work with the specific aims of examining survival, symptom burden and hospitalization rates in a CKM cohort managed within a structured, multidisciplinary KSC programme that has supported and enabled SDM over the last decade.
Nephrol Dial Transplant. 2023;38(2):405-413. © 2023 Oxford University Press
