Survival outcomes of supportive care <i>versus</i> dialysis therapies for elderly patients with end‐stage kidney disease: A systematic review and meta‐analysis

Foote, Celine; Kotwal, Sradha; Gallagher, Martin; Cass, Alan; Brown, Mark; Jardine, Meg

doi:10.1111/nep.12586

Cited by 102 publications

(120 citation statements)

References 26 publications

(39 reference statements)

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“…Non-dialysis options may also be appropriate for patients whose goals and priorities are to focus on the quality of their life rather than treatments aimed to extend life. Although there are no prospective studies comparing survival with dialysis versus conservative management most studies and a recent meta-analysis showed similar survival [67–70]. Patients who choose conservative therapy have relatively preserved functional status until the last months of life [67–69].…”

Section: Main Textmentioning

confidence: 99%

Treatment decisions for older adults with advanced chronic kidney disease

Rosansky

Schell

Shega³

et al. 2017

BMC Nephrol

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Dialysis initiation rates among older adults, aged 75 years or greater, are increasing at a faster rate than for younger age groups. Older adults with advanced CKD (eGFR < 30 ml/min/1.73 m2) typically lose renal function slowly, often suffer from significant comorbidity and thus may die from associated comorbidities before they require dialysis.A patient’s pattern of renal function loss over time in relation to their underlying comorbidities can serve as a guide to the probability of a future dialysis requirement. Most who start dialysis, initiate treatment “early”, at an estimated glomerulofiltration rate (eGFR) >10 ml/min/1.73 m2 and many initiate dialysis in hospital, often in association with an episode of acute renal failure. In the US older adults start dialysis at a mean e GFR of 12.6 ml/min/1.73 m2 and 20.6% die within six months of dialysis initiation. In both the acute in hospital and outpatient settings, many older adults appear to be initiating dialysis for non-specific, non-life threatening symptoms and clinical contexts. Observational data suggests that dialysis does not provide a survival benefit for older adults with poor mobility and high levels of comorbidity. To optimize the care of this population, early and repeat shared decision making conversations by health care providers, patients, and their families should consider the risks, burdens, and benefits of dialysis versus conservative management, as well as the patient specific symptoms and clinical situations that could justify dialysis initiation. The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient’s unique goals and priorities.In conclusion, when considering the morbidity and quality of life impact associated with dialysis, many older adults may prefer to delay dialysis until there is a definitive indication or may opt for conservative management without dialysis. This approach can incorporate all CKD treatments other than dialysis, provide psychosocial and spiritual support and active symptom management and may also incorporate a palliative care approach with less medical monitoring of lab parameters and more focus on the use of drug therapies directed to relief of a patient’s symptoms.

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Section: Main Textmentioning

confidence: 99%

Treatment decisions for older adults with advanced chronic kidney disease

Rosansky

Schell

Shega³

et al. 2017

BMC Nephrol

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“…Currently, in developed nations, the age cohort of dialysis patients that has the highest prevalence are 65–80 year olds . Multiple studies suggest that patients over 75 years with ESKD and significant comorbidities have a similar survivorship to their contemporaries who chose a non‐dialysis pathway . This fact and a recognition of the necessity of improved symptom management, advance care planning and care of the dying patient led to an evolving alliance between the disciplines.…”

Section: Palliative Care and Three Modern Phenomena In Modern Medicinementioning

confidence: 99%

‘To die with dignity’: an update on Palliative Care

Brennan

2017

Internal Medicine Journal

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Significant developments have occurred in the discipline of palliative care in the modern era. This paper shall explore those developments, challenge some widely held misconceptions about the role and daily practice of the discipline, highlight the growing recognition of the role of palliative care in non-malignant diseases, briefly discuss innovations in symptom management and reflect on the underlying principles, maturation and challenges faced by the discipline.Funding: None.

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“…Foote et al (16) reported that the annual survival of patients on hemodialysis or peritoneal dialysis was 73.0% (95% confidence interval, 66.3% to 79.7%) and that the annual survival of patients on conservative management was 70.6% (95% confidence interval, 63.3% to 78.0%), suggesting that the annual mortalities between treatment options were similar. The overall median survival advantage presented by Verberne et al (15), in contrast to results from the systematic review, may reflect differences in patient characteristics between studies and varying definitions in starting points of comparison.…”

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confidence: 99%