Background and Aims With the geriatric population increasing, the patients reaching stage 5 chronic kidney disease (CKD) are older, frailer and have multiple comorbidities. Technological advances in renal replacement therapy (RRT) and easier access to dialysis resulted in an expansion on geriatric dialysis population. Conservative management (CM) is an option that should be considered in this population, where is crucial to balance the survival and quality of life. Beside mortality, with this study we aim to evaluated patient-outcomes (hospitalization, falls and functional capacity) in older and frailer stage 5 CKD patients receiving hemodialysis (HD) and in CM. Method We conducted a single center retrospective study in older (≥ 75years), frailer (Clinical Frailty Scale – CFS ≥ 5) and with multiple comorbidities (modified Charlson comorbidity index – mCCI ≥ 5 and) stage 5 CKD patients, admitted in our Nephrology department between January 1, 2014 to December 31, 2020. The eGFR was calculated through Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) at the time of decision or at the time of starting HD. The comorbidities were stratified using the mCCI and frailty was assessed with CFS at the time of decision in CM group (CMG) and at the start of HD (HDG). We evaluated hospitalizations, falls, CFS one-year later and survival in each group. Survival analysis was performed using the Kaplan–Meier method and was calculated at the beginning of RRT or eGFR ≤ 15ml/min/1.73m2 in CMG. Differences between the two groups were tested with Mann-Whitney U method. Results A total of 76 patients with indication to start RRT were included: 61.8% (n=47) initiated HD and 38.2% (n=29) were in CM. The reasons for CM decision were deterioration of clinical condition (n=11), expected survival less than 6 months (n=8), patient option (n=5) and cognitive impairment (n=5). Clinical characteristics are presented in Table 1. The CMG was older [median, IQR: 88 (85.5-90.5) vs 80 (77.0 – 83.0), p < 0.001] and had a lower BMI [23.44 (21.08 - 25.08) vs 26.23 (23.26 – 29.20), p=0.006]. Both groups did not differ significantly in terms of sex, CKD etiology, comorbidity or frailty. A total of 66 patients died at the end of the study [CMG 100% (n= 29) vs 78.7% HDG (n=37)]. The overall survival has higher on the HDG compared to the CMG with a median survival rate of 503 days (Fig 1). One-year survival rate was 53.5% in HDG vs 24% CMG (p <0.001). The median (IQR) of number of hospitalizations per patient was greater in the HDG [4 (1.5-6.5) vs 3 (0.5-5.5) CMG]. In HDG 17% patients had at least one fall vs 3.4% in CMG. In both groups there was a general deterioration associated to a higher CFS at one-year follow up (p=0.003 HD group vs p=0.015 CMG). Conclusion In our study, hemodialysis was associated to improved survival in older and frailer stage 5 CKD patients compared to CM. However, this group had more hospitalizations, falls and poor functional status. These outcomes have a crucial impact on quality of life in this population and should be consider at the time of treatment decision. One of the limitations of our study was small sample size in both groups. In the future, we consider that is important to perform multicenter studies focused on patients-outcomes. We also think that it’s important to understand the patient and family perspective in terms of quality of life and symptom burden associated to each treatment option.
Summary Chronic kidney disease (CKD) is a silent worldwide epidemic responsible for a high clinical and socioeconomic burden. Beyond disease-related outcomes, there is an urgent need for clinicians to focus on implementation of validated patient-reported outcome measures (PROMs) in routine care practice. This updated concept of high-quality renal care implies a changing paradigm, with a focus on patient experiences and health-related quality of life (HRQL) measures. This is even more crucial in end-stage renal disease, where adequate dialysis should aim at a multidimensional approach instead of only analytical targets. It is vital to emphasize interventions that positively affect the quality of life of the patient with CKD beyond improving their survival. Although the importance of using HRQL measures is well established, there has been resistance to their use in routine care. There are numerous tools to assess HRQL, but not all are easy to apply. It is essential to overcome these possible barriers and better adequate the HRQL tools to the patients. The shorter and simpler instruments are more appealing, as well as the electronic health questionnaires. The EuroQol-5 Dimensions tool (EQ5D) is a standardized measure of health status, is simple and quick, and provides information that can be used in economic assessments of healthcare.In this era of limited health resources, cost analysis and economic evaluations are becoming increasingly relevant. In dialysis units, sustainability management should include a pathway of integrated care, including home and center dialysis, that values the better adjustment of prescriptions to the individual patient. The authors advocate using the EQ5D to support this pathway of quality in dialysis units toward global health gains. The EQ5D is a PROM with a view centered on patient and sustainable health services.
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