Decision making for the initiation and termination of dialysis in patients with advanced cancer

Abstract

Age is a risk factor for both cancer and end‐stage renal disease (ESRD). Newer cancer treatments are allowing patients to live longer with their cancer, the renal toxicity from the cancer itself or from the therapies that was used to treat the malignancy. Consequently, nephrologists will increasingly be asked to evaluate and counsel patients with ESRD and advanced cancer regarding the initiation of dialysis. Data on morbidity, mortality, and quality of life (QOL) outcomes in this population are sparse. Expectations regarding what dialysis can reasonably accomplish in this cohort can be unrealistically high among patients, their family members and the rest of the health care team. This article will discuss some results from the available studies on mortality and QOL outcomes in this cohort and advise the nephrologist about how to approach these challenging discussions.

Incidence of Fractures Before and After Dialysis Initiation

“…Although decision making for dialysis initiation in CKD patients with cancer can be complicated, cancer is in general not a contraindication to dialysis. ( 41 ) The high percentage of patients, 22% in our study, with history of cancer diagnosis within 5 years prior to 1 year before dialysis initiation probably reflects both the high median age of dialysis patients and the increased risk for cancer that accompanies a decline of renal function. ( 42,43 ) The high burden of cancer among patients with ESKD and our observation that fracture risk is increased in dialysis patients with cancer diagnosis underline that improved surveillance to prevent fractures is warranted in these patients.…”

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review

“…Influencing factors related to therapeutic options were also found, such as the possibilities, [ 23 , 28 , 32 , 63 ] effectiveness [ 28 , 32 , 60 ] and usefulness of treatments, [ 55 ] as well as the capacity for tolerance [ 28 , 37 ] and the burden [ 32 ] that the intervention will result in.…”

“…[ 21 , 44 ] On the other hand, there is a need for appreciation of the wishes of the patients or their surrogates , [ 23 , 25 , 26 , 32 , 33 , 62 , 63 ] characterized here as valuing the patient’s culture [ 22 , 48 , 62 ] and their concept of quality of life. [ 21 , 23 , 31 , 37 , 44 , 63 ]…”

KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation

“…Expectations of what dialysis can reasonably accomplish in hematological cancer patients are often unrealistically high among patients and their caregivers 52 ; an estimate of overall prognosis based on each patient's comprehensive status (including age, performance status, frailty, malnutrition, comorbidities, and co-medications) is thus mandatory. An interdisciplinary team approach and improved communication between hematologists/oncologists and nephrologists is necessary for facilitating the discussion on whether to initiate kidney replacement therapy.…”