Medline ® Abstracts for References 12-16
of 'Palliative care: End-stage renal disease'
Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.
Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE
Nephrol Dial Transplant. 2007;22(7):1955.
BACKGROUND: The number of elderly patients with chronic kidney disease (CKD) stage 5 is steadily increasing. Evidence is needed to inform decision-making for or against dialysis, especially in those patients with multiple comorbid conditions for whom dialysis may not increase survival. We therefore compared survival of elderly patients with CKD stage 5, managed either with dialysis or conservatively (without dialysis), after the management decision had been made, and explored which of several key variables were independently associated with survival.
METHODS: A retrospective analysis of the survival of all over 75 years with CKD stage 5 attending dedicated multidisciplinary pre-dialysis care clinics (n=129) was performed. Demographic and comorbidity data were collected on all patients. Survival was defined as the time from estimated GFR<15 ml/min to either death or study endpoint.
RESULTS: One- and two-year survival rates were 84% and 76% in the dialysis group (n=52) and 68% and 47% in the conservative group (n=77), respectively, with significantly different cumulative survival (log rank 13.6, P<0.001). However, this survival advantage was lost in those patients with high comorbidity scores, especially when the comorbidity included ischaemic heart disease.
CONCLUSIONS: In CKD stage 5 patients over 75 years, who receive specialist nephrological care early, and who follow a planned management pathway, the survival advantage of dialysis is substantially reduced by comorbidity and ischaemic heart disease in particular. Comorbidity should be a major consideration when advising elderly patients for or against dialysis.
Department of Palliative Care and Policy, King's College Hospital, London, Se5 9RJ, UK. email@example.com
Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?
Carson RC, Juszczak M, Davenport A, Burns A
Clin J Am Soc Nephrol. 2009;4(10):1611. Epub 2009 Sep 24.
BACKGROUND AND OBJECTIVES: There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT).
DESIGN, SETTING, PARTICIPANTS,&MEASUREMENTS: This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (>or =70 yr) patients who had ESRD and had chosen either MCM (n = 29) or RRT (n = 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.8 ml/min per 1.73 m(2).
RESULTS: Median survival, including the first 90 d, was 37.8 mo (range 0 to 106 mo) for RRT patients and 13.9 mo (range 2 to 44) for MCM patients (P<0.01). RRT patients had higher rates of hospitalization (0.069 [95% confidence interval (CI) 0.068 to 0.070]) versus 0.043 [95% CI 0.040 to 0.047]hospital days/patient-days survived) compared with MCM patients. MCM patients were significantly more likely to die at home or in a hospice (odds ratio 4.15; 95% CI 1.67 to 10.25). A survey of the literature describing elderly ESRD outcomes is also presented.
CONCLUSIONS: Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis.
Nanaimo Regional Hospital, Nanaimo, British Columbia, Canada.
Patients who plan for conservative care rather than dialysis: a national observational study in Australia.
Morton RL, Turner RM, Howard K, Snelling P, Webster AC
Am J Kidney Dis. 2012;59(3):419.
BACKGROUND: It is unclear how many incident patients with stage 5 chronic kidney disease (CKD) referred to nephrologists are presented with information about conservative care as a treatment option and how many plan not to dialyze.
STUDY DESIGN: National observational survey study with random-effects logistic regression.
SETTING& PARTICIPANTS: Incident adult and pediatric pre-emptive transplant, dialysis, and conservative-care patients from public and private renal units in Australia, July to September 2009.
PREDICTORS: Age, sex, health insurance status, language, time known to nephrologist, timing of information, presence of caregiver, unit conservative care pathway, and size of unit.
OUTCOMES& MEASUREMENTS: The 2 main outcome measures were information provision to incident patients about conservative care and initial treatment regardless of planned conservative care.
RESULTS: 66 of 73 renal units (90%) participated. 10 (15%) had a formal conservative-care pathway. Of 721 incident patients with stage 5 CKD, 470 (65%) were presented with conservative care as a treatment option and 102 (14%) planned not to dialyze; median age was 80 years. Multivariate analysis for information provision showed that patients older than 65 years (OR, 3.40; 95% CI, 1.97-5.87) and those known to a nephrologist for more than 3 months (OR, 6.50; 95% CI, 3.18-13.30) were more likely to receive information about conservative care. Patients with conservative care as planned initial treatment were more likely to be older than 65 years (OR, 4.71; 95% CI, 1.77-12.49) and women (OR, 2.23; 95% CI, 1.23-4.02) than those who started dialysis therapy. Those with private health insurance were less likely to forgo dialysis therapy (OR, 0.40; 95% CI, 0.17-0.98).
LIMITATIONS: Cross-sectional design prohibited longer term outcome measurement. Excluded patients with stage 5 CKD managed in the community.
CONCLUSIONS: 1 in 7 patients with stage 5 CKD referred to nephrologists plans not to dialyze. Comprehensive service provision with integrated palliative care needs to be improved to meet the demands of the aging population.
School of Public Health, The University of Sydney, Australia. firstname.lastname@example.org
Functional status of elderly adults before and after initiation of dialysis.
Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE
N Engl J Med. 2009;361(16):1539.
BACKGROUND: It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD).
METHODS: Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL]scale of 0 to 28 points, with higher scores indicating greater functional difficulty).
RESULTS: The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.
CONCLUSIONS: Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status.
Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA. email@example.com
Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.
Verberne WR, Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ
Clin J Am Soc Nephrol. 2016 Apr;11(4):633-40. Epub 2016 Mar 17.
BACKGROUND AND OBJECTIVES: Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.
DESIGN, SETTING, PARTICIPANTS,&MEASUREMENTS: A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded.
RESULTS: In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages≥70 years old with Davies comorbidity scores of≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02).
CONCLUSIONS: In this single-center observational study, there was no statistically significant survival advantage among patients ages≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.
Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands; and firstname.lastname@example.org.