A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Abstract

BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Conservative Management and End-of-Life Care in an Australian Cohort with ESRD

“…Few patients switched to dialysis after a confirmed plan for conservative care, consistent with other studies (7)(8)(9). The low rate of crossover from conservative management to RRT may indicate more anticipatory discussions among those with structured and early access to palliative care.…”

“…The focus of conservative care incorporating palliative care principles is to prioritize comfort and quality of life aligned with patients' goals of care rather than a conventional disease-orientated focus on RRT (particularly dialysis) as rehabilitative treatment (6). It has been reported that patients initially choose conservative care but may change their minds and commence dialysis after their kidney function deteriorates and they feel unwell (7)(8)(9). However, it is unclear what proportion of patients switche to dialysis after an initial plan for conservative care.…”

A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD

“…CKD progression further increases cardiovascular risk (2) and the risk of requiring RRT (3). CKD management aims to reduce these risks and prepare people with advanced CKD for dialysis, transplantation, or conservative care (4). Increasingly, CKD management involves shared decision-making and self-care activities, which are actively promoted in health care policy (5,6).…”

Chapter 5 Survival and Cause of Death in UK Adult Patients on Renal Replacement Therapy in 2016:

“…There is recognised variability in how conservative care is delivered and this is likely to contribute to centre differences in the population who start dialysis, particularly amongst older patients [12]. Historically, the UKRR has been unable to collect data on patients opting for conservative care rather than RRT for their chronic kidney disease.…”