Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease

Hussain, Jamilla; Mooney, Andrew; Russon, Lynne

doi:10.1177/0269216313484380

Cited by 164 publications

(193 citation statements)

References 17 publications

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“…However, adequate survival data, specifically on older patients, are limited. A number of studies, predominantly from the United Kingdom, has determined survival of older patients managed conservatively compared with RRT (9)(10)(11)(12)(13)(14)(15)(16)(17). In these studies, the numbers of recruited patients are generally small, the studies are performed in heterogeneous study populations, and there is significant variability in starting points used in survival analyses (18).…”

Section: Introductionmentioning

confidence: 99%

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Verberne

Geers

Jellema

et al. 2016

Clinical Journal of the American Society of Nephrology

196

190

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Background and objectives Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.Design, setting, participants, & measurements A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages $70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded. ResultsIn total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean6SD: 8364.5 versus 7664.4 years; P,0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P,0.001) and all other starting points (P,0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages $80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages $70 years old with Davies comorbidity scores of $3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02).Conclusions In this single-center observational study, there was no statistically significant survival advantage among patients ages $80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.

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Section: Introductionmentioning

confidence: 99%

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Verberne

Geers

Jellema

et al. 2016

Clinical Journal of the American Society of Nephrology

196

190

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“…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). A conservative care pathway is increasingly recognized as an alternative treatment to dialysis and has been introduced in the United Kingdom (UK) (1,(6)(7)(8)(9)(10), Australia (11,12), other European countries (13)(14)(15), and Asia (16)(17)(18).…”

Section: Introductionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age $75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR,. CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

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“…Clinicians may want to avoid "letting down" their colleagues, who may have invested much in the care of the patient (22); fear litigation or formal complaints; or worry that they did not try hard enough. They may perceive a short trial of dialysis as most appropriate but may place less emphasis on the potential adverse consequences (Table 1), not least the potential to promote the loss of residual renal function and therefore hasten death after dialysis withdrawal (27,28).…”

Section: The Medical Advocate: "Fear Of Doing Wrong"mentioning

confidence: 99%

Should an Elderly Patient with Stage V CKD and Dementia Be Started on Dialysis?

Ying

Levitt

Jassal

2014

Clinical Journal of the American Society of Nephrology

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The burden of cognitive impairment appears to increase with progressive renal disease, such that the prevalence of dementia among those starting dialysis, or those already established on dialysis, is high. The appropriateness of dialysis initiation in this population has been questioned, and current Renal Physician Association guidelines suggest forgoing dialysis in individuals who have dementia and lack awareness of self and environment. Patients are, however, also entitled to equal rights and respect, equal access to health care services, and an opportunity to engage in shared decision-making processes, particularly if there is concern over reversibility of disease. This article discusses, on the basis of principles of beneficence and nonmaleficence, the arguments in favor of and against dialysis use, and the process of determining an appropriate care plan. Factors discussed include the current societal trend toward a technological imperative, premature fatalism, survival benefits, and the implications of providing care to patients who are unable to express their tolerance for symptoms associated with the treatment or lack of treatment.

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Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease

Cited by 164 publications

References 17 publications

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Conservative Care for ESRD in the United Kingdom

Should an Elderly Patient with Stage V CKD and Dementia Be Started on Dialysis?

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