Factors Affecting Survival in Advanced Chronic Kidney Disease Patients Who Choose Not to Receive Dialysis

Wong, Christopher F.; McCarthy, Molly; Howse, Matthew; Williams, Peter S.

doi:10.1080/08860220701459634

Cited by 85 publications

(78 citation statements)

References 9 publications

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“…The survey respondents' roles varied; respondents described themselves as clinical leads (20), consultant nephrologists (17), nurses (15), and clinical directors (9). Thirty-two units indicated that the survey respondent consulted other staff member(s) when completing it.…”

Section: Resultsmentioning

confidence: 99%

“…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%

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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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Section: Resultsmentioning

confidence: 99%

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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“…The survival of a median 16 months and 53% 12 month survival in our RSC-NFD group is within the range reported by O'Connor et al (27) and others (20,(28)(29)(30)(31)(32)(33). Hussain and colleagues (34) retrospectively analyzed outcomes of 172 patients aged .70 years managed via a nondialysis pathway and 269 who were planned for dialysis.…”

Section: Survivalmentioning

confidence: 97%

CKD in Elderly Patients Managed without Dialysis

Brown

Collett

Josland

et al. 2015

Clinical Journal of the American Society of Nephrology

183

229

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Background and objectives Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis.Design, setting, participants, & measurements In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale -Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic.Results Nondialysis patients were older than the predialysis group (82 versus 67 years; P,0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m 2 ; P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived .12 months after eGFR fell below 10 ml/min per 1.73 m 2 . For the whole group, age, serum albumin, and eGFR ,15 ml/min per 1.73 m 2 were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL.Conclusions Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.

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“…3,[6][7][8][9][10][11][12][13] We believe that our data, which show the median survival after the decline in the eGFR to less than 15 mL/min/1.73 m 2 of more than one year, may be reasonable, while it must be noted that that our cohort included an elderly CKD patient who survived for more than three years and two patients who survived for more than one year after the initial referral with eGFRs already below 15 mL/min/1.73 m 2 . This may not be surprising since more than one-third of the subjects over 80 years of age referred to a nephrology center has a severe but nonprogressive renal dysfunction, and this subgroup has a lower mortality rate than those with a progressive deterioration of the renal function.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 Factors affecting the decision of whether to start dialysis treatment have been evaluated as well. 8 However, qualitative and quantitative analyses regarding the outcomes of end-stage CKD patients who opt for conservative managements are limited, 3,6,[8][9][10][11][12][13] although a few studies have compared the survival of conservatively managed patients with the subjects commencing dialysis treatment and demonstrated the scarce benefit of such a procedure among the dependent patients with significant comorbidities. 3,6,8,10 The decisions regarding terminal health care of the elderly are complex and confusing in Japan, presumably because of family emotions, religion, social customs, and public opinion.…”

Section: Introductionmentioning

confidence: 99%

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

Akimoto

Ito²,

Takahashi³

et al. 2015

Clinical Medicine Insights: Geriatrics

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ABSTR ACT: There is little descriptive information regarding the conservative management of Japanese end-stage chronic kidney disease (CKD) patients. We carried out a retrospective case series analysis of elderly Japanese end-stage CKD patients who were hospitalized and died without the provision of renal replacement therapy (RRT) programs. A total of 25 consecutive patients followed by a nephrologist for a median of 443 days with a mean age of 81.7 ± 7.5 years were included. The most common symptom on admission was appetite loss in 17 patients (68%). Fifty percent of the patients died within 394 days of follow-up after their estimated glomerular filtration rate (eGFR) fell below 15 mL/min/1.73 m 2 and 222 days of follow-up after the eGFR fell below 10 mL/min/1.73 m 2 . The validity of our findings for Japanese patients with end-stage CKD must be evaluated in greater detail.

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Factors Affecting Survival in Advanced Chronic Kidney Disease Patients Who Choose Not to Receive Dialysis

Cited by 85 publications

References 9 publications

Conservative Care for ESRD in the United Kingdom

Conservative Care for ESRD in the United Kingdom

CKD in Elderly Patients Managed without Dialysis

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

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