Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review

Abstract

Background Patients with stage 5 chronic kidney disease (CKD5) collaborate with their clinicians when choosing their future treatment modality. Most elderly patients with CKD5 may only have two treatment options: dialysis or conservative kidney management (CKM). The objective of this systematic review was to investigate whether CKM offers a quantity or quality of life benefit compared to dialysis for some patients with CKD5. Methods The databases MEDLINE, EMBASE, the Cochrane Library, and CINAHL were systematically searched for studies comparing patients with CKD5 who had chosen or were treated with either CKM or dialysis. The primary outcomes were mortality and quality of life (QoL). Hospitalization, symptom burden, and place of death were secondary outcomes. For studies reporting hazard ratios, pooled values were calculated, and forest plots conducted. Results Twenty-five primary studies, all observational, were identified. All studies reported an increased mortality in patients treated with CKM (pooled hazard ratio 0.47, 95 % confidence interval 0.34–0.65). For patients aged ≥ 80 years and for elderly individuals with comorbidities, results were ambiguous. In most studies, CKM seemed advantageous for QoL and secondary outcomes. Findings were limited by the heterogeneity of studies and biased outcomes favouring dialysis. Conclusions In general, patients with CKD5 who have chosen or are on CKM live for a shorter time than patients who have chosen or are on dialysis. In patients aged ≥ 80 years old, and in elderly individuals with comorbidities, the survival benefits of dialysis seem to be lost. Regarding QoL, symptom burden, hospitalization, and place of death, CKM may have advantages. Higher quality studies are needed to guide patients and clinicians in the decision-making process.

Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis

“…One of the distinct benefits afforded by conservative kidney management is that patients who choose this option experience less intensive care near the end of life than patients who receive dialysis. 6,22,30,42,43,51 However, it also is recognized that patients who forgo dialysis receive hospice services less often and die in the hospital setting more often than other patients in the same health system but with other serious illness, such as terminal cancer. 51 More research is needed to understand and overcome the barriers to supportive care for this population.…”

“…Toward this end, several systematic reviews and meta-analyses [3][4][5][6][7] have been conducted comparing outcomes between patients treated with dialysis and those treated conservatively. They show that dialysis is associated with longer survival compared with conservative approaches [3][4][5][6] but that these survival advantages are attenuated with increasing age and comorbidity.…”

“…Toward this end, several systematic reviews and meta-analyses [3][4][5][6][7] have been conducted comparing outcomes between patients treated with dialysis and those treated conservatively. They show that dialysis is associated with longer survival compared with conservative approaches [3][4][5][6] but that these survival advantages are attenuated with increasing age and comorbidity. 7 Patients treated conservatively also spend less time in the hospital and die there less often compared with patients receiving dialysis, 6 and early changes in quality of life appear similar between treatment groups.…”

“…They show that dialysis is associated with longer survival compared with conservative approaches [3][4][5][6] but that these survival advantages are attenuated with increasing age and comorbidity. 7 Patients treated conservatively also spend less time in the hospital and die there less often compared with patients receiving dialysis, 6 and early changes in quality of life appear similar between treatment groups. 7,8 Although the findings of these prior studies help to inform shared decision-making about treatment of advanced CKD, they are restricted to studies comparing groups treated with dialysis and those treated conservatively.…”

Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review

“… 46 A recent systematic review found that CKM may be associated with improved quality of life and lower symptom burden and hospitalization. 47 Of note, the intended purpose of this review is not so much to make a direct head-to-head comparison of dialysis versus CKM but rather to illustrate the potential expected life trajectory of an older individual with advanced CKD managed either conservatively or with a dialysis pathway. It is clear that not all patients are suitable for or will benefit from kidney replacement therapy, particularly in those who are frail or highly comorbid.…”