Choosing Not to Dialyse: Evaluation of Planned Non-Dialytic Management in a Cohort of Patients with End-Stage Renal Failure

Abstract

Objectives: To study factors influencing the recommendation for palliative (non-dialytic) treatment in patients approaching end-stage renal failure and to study the subsequent outcome in patients choosing not to dialyse. Design: Cohort study of patients approaching end-stage renal failure who underwent multidisciplinary assessment and counselling about treatment options. Recruitment was over 54 months, and follow-up ranged from 3 to 57 months. Groups were defined on the basis of the therapy option recommended (palliative or renal replacement therapy). Setting: Renal unit in a district general hospital serving a population of about 1.15 million people. Subjects: 321 patients, mean age ± SD 61.5 ± 15.4 years (range: 16–92), 57% male, 30% diabetic. Main Outcome Measures: Survival, place of death (hospital or community). Results: Renal replacement therapy was recommended in 258 patients and palliative therapy in 63 (19.6%). By logistic regression analysis, patients recommended for palliative therapy were more functionally impaired (modified Karnofsky scale), older and more likely to have diabetes. The comorbidity severity score was not an independent predictor. Thirty-four patients eventually died during palliative treatment, 26 of whom died of renal failure. Ten patients recommended for palliative treatment opted for and were treated by dialysis. Median survival after dialysis initiation in these patients (8.3 months) was not significantly longer than survival beyond the putative date of dialysis initiation in palliatively treated patients (6.3 months). 65% of deaths occurring in dialysed patients took place in hospital compared with 27% in palliatively treated patients (p = 0.001). Conclusions: In high-risk, highly dependent patients with renal failure, the decision to dialyse or not has little impact on survival. Dialysis in such patients risks unnecessary medicalisation of death.

Cognitive Impairment in the Aging Dialysis and Chronic Kidney Disease Populations: An Occult Burden

“…Most hemodialysis patients are vasculopaths, with high rates of hypertension (80%), diabetes (60%) (14), markedly elevated levels of inflammatory markers and homocysteine (27), vascular endothelial dysfunction (28), cardiovascular events including stroke (29,30), and carotid atherosclerosis (31), all of which contribute to vascular cognitive impairment (23) and neurodegenerative diseases such as Alzheimer's disease (18,32). Ischemic cerebrovascular disease and underlying vascular endothelial pathology however appear to play the largest roles in the genesis of cognitive impairment in CKD and hemodialysis patients.…”

Quality of Life and Survival in Patients with Advanced Kidney Failure Managed Conservatively or by Dialysis

“…Many elderly patients with advanced CKD have several comorbid conditions and increased dependency (4). The benefits of dialysis in this setting may not be clearcut (5,6). Dialysis can impose additional burdens, including invasive interventions, time commitment, and what may be considered overmedicalization of dying.…”

“…Conservative kidney management (CKM) aims to provide a comprehensive package of care to patients choosing to forego dialysis (5). CKM shifts focus from efforts to prolong life to those emphasizing supportive care, maintenance of quality of life (QoL), and control of symptoms.…”

“…Most studies of patient survival in CKM imply that in elderly dependent patients with high comorbidity, dialysis confers only a small survival advantage, overall (5,6) or in terms of hospital-free days (9). Women have a better prognosis on CKM than men, and older patients than younger (10).…”

Conservative Care for ESRD in the United Kingdom

“…The increase in the rate of RRT in recent decades has been greatest among elderly people, many of whom are frail and have multiple comorbid conditions (1,2). Starting dialysis was associated with a substantial and sustained decline in functional status among nursing home residents (3), and RRT may not be beneficial in the context of increasing frailty and loss of independence (4)(5)(6).…”