Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Carson, Rachel C.; Juszczak, Maciej; Davenport, Andrew; Burns, Áine

doi:10.2215/cjn.00510109

Cited by 398 publications

(413 citation statements)

References 43 publications

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“…Carson et al, using similar methods in patients older than 70 years, found median survival durations of 13.9 months in CKM patients and 37.8 months in dialysis patients (9). CKM patients were older but had similar comorbidity.…”

Section: Discussionmentioning

confidence: 97%

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

Silva-Gane

Wellsted

Greenshields

et al. 2012

Clinical Journal of the American Society of Nephrology

183

199

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SummaryBackground and objectives Benefits of dialysis in elderly dependent patients are not clearcut. Some patients forego dialysis, opting for conservative kidney management (CKM). This study prospectively compared quality of life and survival in CKM patients and those opting for dialysis.Design, setting, participants, & measurements Quality-of-life assessments (Short-Form 36, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale) were performed every 3 months for up to 3 years in patients with advanced, progressive CKD (late stage 4 and stage 5).Results After 3 years, 80 and 44 of 170 patients had started or were planned for hemodialysis (HD) or peritoneal dialysis, respectively; 30 were undergoing CKM; and 16 remained undecided. Mean baseline estimated GFR ± SD was similar (14.0±4.0 ml/min per 1.73 m 2 ) in all groups but was slightly higher in undecided patients. CKM patients were older, more dependent, and more highly comorbid; had poorer physical health; and had higher anxiety levels than the dialysis patients. Mental health, depression, and life satisfaction scores were similar. Multilevel growth models demonstrated no serial change in quality-of-life measures except life satisfaction, which decreased significantly after dialysis initiation and remained stable in CKM. In Cox models controlling for comorbidity, Karnofsky performance scale score, age, physical health score, and propensity score, median survival from recruitment was 1317 days in HD patients (mean of 326 dialysis sessions) and 913 days in CKM patients. ConclusionsPatients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.

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Section: Discussionmentioning

confidence: 97%

“…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).…”

Section: Introductionmentioning

confidence: 99%

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

Silva-Gane

Wellsted

Greenshields

et al. 2012

Clinical Journal of the American Society of Nephrology

183

199

View full text Add to dashboard Cite

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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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“…For example, nephrology literature highlights similar themes with older adults facing decisions about dialysis and kidney transplantation. [51][52][53][54][55][56] The incidence of end stage renal disease is increasing more quickly among older adults than any other age group and is associated with a low QOL and high mortality. 51 Given this trend, nephrology practice guidelines were developed to promote patients' active participation in the decision-making process.…”

Section: Older Patients With Other Diseases: Decision Making In Nephrmentioning

confidence: 99%

Process of allogeneic hematopoietic cell transplantation decision making for older adults

Randall

Keven

Atlı

et al. 2015

Bone Marrow Transplant

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Allogeneic hematopoietic cell transplantation (alloHCT) may be the only curative option for some older adults with hematologic malignancies, and its associated risks of significant morbidity and mortality warrant a clear, informed decision-making process. As older adults have not been transplanted routinely until recent years, younger people have been the prototypical group around whom the current process has developed. Yet, this process is applied to older adults who have different considerations than younger patients when making their transplant decision. Older adults do not have the open-ended lives of younger patients and are entitled to consider how to spend their remaining time. They also possess maturity and experience, and with proper knowledge, they can make informed choices rather than moving forward in the transplant process unaware. Notably, older patients face similar problems with the informed decision-making process in nephrology. Strategies such as providing education about alloHCT gradually and repeatedly during induction, presenting recent knowledge from the literature in plain language, and utilizing a team approach to patient education may help older adults make the best decision about transplant in light of their situation and values. Understanding when and how older adults decide on alloHCT is an important first step to further exploring this problem.

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Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Cited by 398 publications

References 43 publications

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

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

Conservative Care for ESRD in the United Kingdom

Process of allogeneic hematopoietic cell transplantation decision making for older adults

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