Palliative care in end-stage kidney disease

The timing of dialysis and kidney transplantation in type 1 diabetes

Despite significant improvements in the treatment of diabetic nephropathy over the last 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease (ESRD) and high mortality once ESRD develops. The timing of dialysis initiation has occurred earlier over the years, but a recent study has led to a re-evaluation of that approach. People with type 1 diabetes treated with pre-dialysis (pre-emptive) transplantation have a lower death rate than people with type 1 diabetes treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared to transplantation while on dialysis. Multiple barriers remain that prevent people with type 1 diabetes from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists and nephrologists, late referral for transplantation, patient and family misconceptions about timing of transplantation and who can be a donor. New data on both the optimal time to initiate dialysis or to pursue transplantation will be reviewed.

Meta-analysis of the relationship between ACE I/D gene polymorphism and end-stage renal disease in patients with diabetic nephropathy

AIMS

  Diabetic nephropathy (DN) is the major cause for end-stage renal disease (ESRD) and the pathogenesis for DN developing into ESRD is not clear at present. Results from published studies on the relationship between angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphism and ESRD risk in DN patients are still conflicting. This meta-analysis was performed to evaluate the association between ACE I/D gene polymorphism and ESRD risk in DN patients.

METHODS

  Association studies were identified from the databases of PubMed, Embase and Cochrane Library on 1 October 2011, and eligible investigations were identified and synthesized using the meta-analysis method. Results were expressed using odds ratios (OR) for dichotomous data and 95% confidence intervals (CI) were also calculated.

RESULTS

  Twelve studies reporting the relation between ACE I/D gene polymorphism and ESRD risk in DN patients were identified. In overall populations, there was a notable association between D allele or DD genotype and ESRD susceptibility (D: OR = 1.32, 95% CI: 1.11-1.56, P = 0.002; DD: OR = 1.67, 95% CI: 1.25-2.21, P = 0.0004). In the sub-group analysis according to ethnicity, D allele or DD genotype was associated with ESRD risk in Asians. In Caucasians, the association of DD genotype with ESRD risk was observed, but the D allele was not. Furthermore, ACE I/D gene polymorphism was associated with ESRD risk in patients with DN due to diabetes mellitus type 2, but the association was not found for patients with DN due to diabetes mellitus type-1.

CONCLUSIONS

  Our results indicate that D allele or DD homozygous is associated with the ESRD susceptibility in DN patients. However, more investigations are required to further this association.

Conservative management of end-stage renal disease without dialysis: a systematic review

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 whether dialysis prolongs survival in the elderly versus conservative, nondialytic management. Any survival benefit from dialysis decreases with comorbidities, especially ischemic heart disease. Patients managed conservatively report a high symptom burden, underscoring the need for concurrent palliative care. Additional head-to-head studies are needed to compare the symptoms of age-matched dialysis patients, but preliminary studies suggest that QOL is similar.

CONCLUSIONS

Conservative management is an important alternative to discuss when counseling patients and families about dialysis. Unlike withdrawal of dialysis in which imminent death is expected, patients who decline dialysis initiation can live for months to years with appropriate supportive care.

Conservative management of end-stage renal disease without dialysis: a systematic review

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 whether dialysis prolongs survival in the elderly versus conservative, nondialytic management. Any survival benefit from dialysis decreases with comorbidities, especially ischemic heart disease. Patients managed conservatively report a high symptom burden, underscoring the need for concurrent palliative care. Additional head-to-head studies are needed to compare the symptoms of age-matched dialysis patients, but preliminary studies suggest that QOL is similar.

CONCLUSIONS

Conservative management is an important alternative to discuss when counseling patients and families about dialysis. Unlike withdrawal of dialysis in which imminent death is expected, patients who decline dialysis initiation can live for months to years with appropriate supportive care.

Patients who plan for conservative care rather than dialysis: a national observational study in Australia

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.