Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy
01 May 2011-Nephrology Dialysis Transplantation (Oxford University Press)-Vol. 26, Iss: 5, pp 1608-1614
TL;DR: In patients aged > 75 years with high extra-renal comorbidity, the survival advantage conferred by RRT over CM is likely to be small and age >75 years and female gender independently predicted better survival.
Abstract: © The Author 2010. Published by Oxford University Press on behalf of the ERA-EDTA. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited
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University of Alberta1, University of British Columbia2, West Virginia University3, Post Graduate Institute of Medical Education and Research4, The George Institute for Global Health5, Hammersmith Hospital6, St George's Hospital7, King's College London8, University of the Witwatersrand9, Tufts University10, Salford Royal NHS Foundation Trust11, University of Oxford12, University of Sydney13, Panamerican University14
TL;DR: The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis.
373 citations
TL;DR: Conservative management of end-stage renal disease patients managed conservatively report a high symptom burden, underscoring the need for concurrent palliative care, and preliminary studies suggest that QOL is similar.
Abstract: Purpose: To summarize evidence on conservative, nondialytic management of end-stage renal disease regarding 1) prognosis and 2) symptom burden and quality of life (QOL). Methods: Medline, Cinahl, and Cochrane were searched for records indexed prior to March 1, 2011. Bibliographies of articles and abstracts from recent meetings were reviewed. Authors and nephrologists were contacted to identify additional studies. Articles were reviewed by two authors and selected if they described stage 5 chronic kidney disease (CKD) patients managed without dialysis, including one or more of the following outcomes: prognosis, symptoms, or QOL. Levels of evidence ratings were assigned using the SORT (Strength of Recommendation Taxonomy) system. Data was abstracted independently by two authors for descriptive analysis. Results: Thirteen studies were included. In studies of prognosis, conservative management resulted in median survival of at least six months (range 6.3 to 23.4 months). Findings are mixed as to whet...
206 citations
TL;DR: Quality of life and survival in CKM patients and those opting for dialysis maintained quality of life, and 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.
Abstract: Summary Background 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 m2) 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. Conclusions Patients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.
186 citations
TL;DR: Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented.
Abstract: The treatment of chronic kidney disease (CKD) and of end-stage renal disease (ESRD) imposes substantial societal costs. Expenditure is highest for renal replacement therapy (RRT), especially in-hospital haemodialysis. Redirection towards less expensive forms of RRT (peritoneal dialysis, home haemodialysis) or kidney transplantation should decrease financial pressure. However, costs for CKD are not limited to RRT, but also include nonrenal health-care costs, costs not related to health care, and costs for patients with CKD who are not yet receiving RRT. Even if patients with CKD or ESRD could be given the least expensive therapies, costs would decrease only marginally. We therefore propose a consistent and sustainable approach focusing on prevention. Before a preventive strategy is favoured, however, authorities should carefully analyse the cost to benefit ratio of each strategy. Primary prevention of CKD is more important than secondary prevention, as many other related chronic diseases, such as diabetes mellitus, hypertension, cardiovascular disease, liver disease, cancer, and pulmonary disorders could also be prevented. Primary prevention largely consists of lifestyle changes that will reduce global societal costs and, more importantly, result in a healthy, active, and long-lived population. Nephrologists need to collaborate closely with other sectors and governments, to reach these aims.
185 citations
TL;DR: In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM, and comorbidity was associated with a lower survival advantage.
Abstract: 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 P P 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.
181 citations
Cites background from "Survival of elderly patients with s..."
...Chandna et al. (11) and Murtagh et al. (15) both found no survival advantage of choosing RRT over CM in patients .75 years old with high comorbidity scored with a self–designed comorbidity score and the Davies comorbidity score, respectively....
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References
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TL;DR: The initiation of dialysis is associated with a substantial and sustained decline in functional status among nursing home residents with ESRD, and this decline was independent of age, sex, race, and functional-status trajectory before the initiation ofdialysis.
Abstract: 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 dia...
888 citations
"Survival of elderly patients with s..." refers background in this paper
...The prospects for rehabilitation in such patents tend to be slim, and prognosis is often poor [5,6]....
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TL;DR: Greater amounts of visceral and hepatic adipose tissue, in conjunction with the lack of a possible protective effect of estrogen, may be related to higher insulin resistance in men compared with women.
726 citations
"Survival of elderly patients with s..." refers background in this paper
...Other authors have suggested that these differences are abolished when corrected for body weight, though the validity of such normalization is debated [20,21]....
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...Notwithstanding this, there are major gender differences in body composition and insulin resistance that may be relevant [21]....
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TL;DR: 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.
Abstract: Background. The number of elderly patients with chronic kidney disease (CKD) stage 5 is steadily increasing. Evidence is needed to inform decisionmaking 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 ¼ 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 ¼ 52) and 68% and 47% in the conservative group (n ¼ 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.
603 citations
"Survival of elderly patients with s..." refers background in this paper
...In the comparative studies, dialysis for elderly patients with high comorbidity did not confer a significant survival advantage over conservative management [10,12], at least in terms of...
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...948 Ethnicity (non-white [12] compared with white [171]) 0....
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...found survival from an eGFR of 15 mL/min to be similar at around 22 months in patients >75 years with high comorbidity in the conservative and dialysed groups [12]....
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TL;DR: 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 choice hemodialysis.
Abstract: 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 (≥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 m2.
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.
410 citations
"Survival of elderly patients with s..." refers background in this paper
...8 months in RRT patients, though hospital-free survivalwas similar in both groups [13]....
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TL;DR: It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians.
Abstract: The fate of octogenarians reaching end-stage renal disease (ESRD) is poorly defined, and implicit dialysis rationing may be practiced in this age group. The main objectives of this study were to analyze the characteristics of pre-ESRD octogenarians offered dialysis or not and to identify factors influencing mortality while on dialysis, to improve prognosis assessment and decision-making. In this single-center cohort, 146 consecutive pre-ESRD octogenarians were referred to a nephrology unit over a 12-yr period (1989 to 2000). Main outcome measures were baseline characteristics of patients offered dialysis and conservative therapy and overall and 1-yr survival according to effective treatment. A therapeutic decision was made for 144 patients. Octogenarians who were not proposed dialysis (n = 37) differed from those who were proposed dialysis (n = 107) mainly in terms of social isolation (43.3% versus 14.7%; P = 0.03), late nephrologic referral (51.4% versus 28.9%; P = 0.01), Karnofsky score (55 +/- 18 versus 63 +/- 20; P = 0.03), and diabetic status (22.2% versus 6.5%, P = 0.008). Six patients refused the dialysis proposal. During the 12-yr observation period, 99 patients died (68.7%). Median survival was 28.9 mo (95% CI, 24 to 38) in patients undergoing dialysis, compared with 8.9 mo (95% CI, 4 to 10) in patients treated conservatively (P < 0.0001). In multivariable piecewise Cox analysis, independent predictors of death within 1 yr on dialysis were poor nutritional status, late referral, and functional dependence. Included in a survivor function, these covariates predict groups with low and high 1-yr mortality risk. Beyond 1 yr on dialysis, the only independent predictor of death was the presence of peripheral vascular disease. It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians. Although most patients on dialysis experienced a substantial prolongation of life, identification of mortality predictors in this age group should improve the process of decision-making regarding the expected benefit of renal replacement therapy.
287 citations