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

Supportive Care: Time to Change Our Prognostic Tools and Their Use in CKD

In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patients' priorities that are important and relevant to them. Because of limits of available scores, the contribution of new prognostic tools with specific markers of the trajectories for patients with CKD and patients' health reports should be evaluated in relation to their transportability to different clinical and cultural contexts and their potential for integration into the decision-making processes. The benefit of their use then needs to be quantified in clinical practice by outcome studies including health-related quality of life, patient and caregiver satisfaction, or utility for improving clinical management pathways and tailoring individualized patient-centered strategies of care. Future research also needs to incorporate qualitative methods involving patients and their caregivers to better understand the barriers and facilitators to use of these tools in the clinical setting. Information given to patients should be supported by a more realistic approach to what dialysis is likely to entail for the individual patient in terms of likely quality and quantity of life according to the patient's values and goals and not just the possibility of life prolongation.

Diagnósticos, resultados e intervenções de enfermagem para pacientes em diálise peritoneal

Resumo Objetivo: Identificar os principais diagnósticos, resultados e intervenções de enfermagem, e validar uma proposta de plano de cuidados para pacientes em diálise peritoneal. Métodos: Estudo transversal com 68 pacientes em centro de referência para doenças renais, seguindo as etapas: elaboração dos Diagnósticos de Enfermagem a partir da NANDA-Internacional; proposta inicial de resultados e intervenções de enfermagem, conforme a Nursing Outcomes Classification e Nursing Interventions Classification; e elaboração de um plano de cuidados com validação por especialistas. Resultados: Identificaram-se seis diagnósticos com frequência acima de 50% e foram propostos 16 resultados e 35 intervenções de enfermagem. No processo de validação realizado por enfermeiros especialistas, foram selecionados oito resultados e 21 intervenções com índice de concordância muito bom (≥0,8). Conclusão: O estudo permitiu identificar diagnósticos e selecionar resultados e intervenções de enfermagem para aplicação na prática clínica, com vistas a subsidiar o processo de cuidado e o conhecimento das taxonomias de enfermagem.

Protein-controlled versus restricted protein versus low protein diets in managing patients with non-dialysis chronic kidney disease: a single centre experience in Australia

Nutrition has been an important part of medical management in patients with chronic kidney disease for more than a century. Since the 1970s, due to technological advances in renal replacement therapy (RRT) such as dialysis and transplantation, the importance of nutrition intervention in non-dialysis stages has diminished. In addition, it appears that there is a lack of high-level evidence to support the use of diet therapy, in particular the use of low protein diets to slow down disease progression. However, nutrition abnormalities are known to emerge well before dialysis is required and are associated with poor outcomes post-commencing dialysis. To improve clinical outcomes it is prudent to incorporate practice research and quality audits into routine care, as part of the continuous clinical practice improvement process. This article summarises the experience of and current practices in a metropolitan tertiary teaching hospital in Sydney, Australia.

Measuring health-related quality of life in patients with conservatively managed stage 5 chronic kidney disease: limitations of the Medical Outcomes Study Short Form 36: SF-36

PURPOSE

Chronic kidney disease (CKD) negatively affects health-related quality of life (HRQoL), which is often measured using the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. However, the adequacy of SF-36 in this population has not been reported. We aimed to determine floor and ceiling effects and responsiveness to change of SF-36 in patients with conservatively managed stage 5 CKD.

METHODS

SF-36 data were collected prospectively. Floor and ceiling effects were estimated for each SF-36 scale and summary measure based on raw scores. The minimal clinically important difference (MCID) was estimated using a combination of anchor-based and distribution-based methods. Responsiveness to change was assessed by comparing MCID for each scale and summary measure to its smallest detectable change.

RESULTS

SF-36 data were available for 73 of the 74 study participants. Using baseline data, floor and/or ceiling effects were detected for 3 of the 8 SF-36 scales. The anchor-based estimation of MCID based on differences in baseline functional status yielded the most reliable results. For the physical component summary, MCID was estimated at 5.7 points. Whilst the two SF-36 summary measures were responsive to change and free of floor and/or ceiling effects, six of the eight scales were not.

CONCLUSIONS

This small study of patients with conservatively managed stage 5 CKD found that only the summary measures of SF-36 and 2 of its 8 scales can be used to assess changes in HRQoL over time. These findings suggest that in this population, alternative HRQoL assessment tools should be considered for future studies.

Rate of Decline of Kidney Function, Modality Choice, and Survival in Elderly Patients with Advanced Kidney Disease

AIM

In elderly, dependent patients with advanced chronic kidney disease, dialysis may confer only a small survival advantage over conservative kidney management (CKM). We investigated the role of rate of decline of kidney function on treatment choices and survival.

METHODS

We identified a retrospective (1995-2010) cohort of patients aged over 75 years, with progressive kidney impairment and an estimated glomerular filtration rate (eGFR) between 10 and 15 ml/min/1.73 m2. All subsequently chose to be treated by either dialysis or CKM. Patients were followed for a minimum of 3 years.

RESULTS

Of 250 patients identified, 92 (37%) opted for dialysis and 158 (63%) for CKM. Mean age was 80.9 ± 4.0 years. eGFR was 13.3 ± 1.4 initially and 8.7 ± 3.0 ml/min/1.73 m2 at follow-up. Both were similar in those on dialysis and CKM pathways. Rate of decline of eGFR was more rapid in those choosing dialysis (0.45 (interquartile range, IQR 0.64) vs. 0.21 (IQR 0.28) ml/min/1.73 m2/month, p < 0.001), and independently predicted choice of CKM. In patients with high comorbidity, choice of dialysis was associated with a non-significant adjusted survival advantage of 5 months. Inclusion in models of time dependent eGFR during follow-up (eGFRtd) - a reflection of the rate of decline of kidney function - showed it to be independently associated with mortality risk in those on the CKM (p < 0.001) but not on the dialysis pathway. CKM pathway patients at the 25th centile of eGFRtd had an adjusted survival of 7 months compared to 63 months for those at the 75th centile.

CONCLUSIONS

Rate of decline of kidney function is a determinant of CKM choice in elderly patients and is associated with mortality risk in patients of the CKM pathway. These findings should inform counselling.

The Symptoms Prevalence, Medical Interventions, and Health Care Service Needs for Patients With End-Stage Renal Disease in a Renal Palliative Care Program

A retrospective study was conducted to evaluate the symptoms prevalence and interventions initiated in the last 2 weeks of life, health care service utilization, and causes of death of patients with end-stage renal disease (ESRD under a renal palliative care (RPC) program. A total of 335 RPC patients were included, of which 226 patients died during the study period. The 5 most prevalent symptoms were dyspnea (63.7%), fatigue (51.8%), edema (48.2%), pain (44.2%), and anorexia (38.1%); and the 5 most prevalent interventions initiated were oxygen (69.5%), parenteral infusion (67.3%), antibiotics (53.5%), bladder catheterization (44.7%), and analgesic (39.8%) in the last 2 weeks of life. Each patient received 3.5 ± 4.4 outpatient clinic visit, 3.4 ± 10.3 home care visits, and 3.1 ± 2.7 hospital admissions. Besides ESRD (51.8%), the most common causes of death were cardiovascular events (18.6%) and infection (17.2%).

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

BACKGROUND AND OBJECTIVES

Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015.

RESULTS

In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups.

CONCLUSIONS

Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

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.

Special considerations for the treatment of chronic kidney disease in the elderly

Chronic kidney disease (CKD) is common in older adults, and its burden is expected to increase in older populations. Even if the knowledge on the approach to older patient with CKD is still evolving, current guidelines for pharmacological management of CKD does not include specific recommendations for older patients. Additionally, decision-making on renal replacement therapy (RRT) for older patients is far from being evidence-based, and despite the improvement in dialysis outcomes, RRT may cause more harm than benefit compared with conservative care when prognostic stratification is not carefully assessed. The use of comprehensive geriatric assessment tools could help clinicians in applying a more informed decision-making. Finally, physical exercise and rehabilitation interventions also represents a promising therapeutic strategy.

Quality of Life of Patients with Advanced Chronic Kidney Disease Receiving Conservative Care without Dialysis

With the evidence that dialysis may not necessarily be beneficial for older adults with advanced chronic kidney disease (CKD), there is a growing interest in promoting conservative care without dialysis as a viable treatment option for these individuals. This review summarizes the current empirical evidence of symptom experiences and quality of life of patients receiving conservative care. Data suggest that conservative care may yield symptom experiences and quality of life that are compatible with those of patients on dialysis. However, these data are exclusively from studies conducted outside of the United States in which there were often no comparison groups or study designs that could provide high quality evidence. There is an urgent need for further research and developing a conservative care model suitable for CKD populations in the U.S.

End-Stage Kidney Disease in the Elderly: Approach to Dialysis Initiation, Choosing Modality, and Predicting Outcomes

The number of patients with end-stage kidney disease 65 years and older is growing, and this growth is expected to continue. The presence of medical comorbidities, limited life expectancy, frailty, and poor functional status in these patients poses substantial challenges in clinical decision-making and provision of optimal care. Frailty is more common in elderly patients with CKD than without and is associated with poor outcomes. Several prognostic tools were developed to estimate the rate of CKD progression among elderly, and risk of mortality after dialysis initiation. Risk factors for CKD progression among elderly include low estimated glomerular filtration rate, high baseline proteinuria, acute kidney injury, low serum albumin, and presence of congestive heart failure. The decision to initiate dialysis in the elderly should take into consideration life expectancy, risks and benefits of each dialysis modality, quality of life, and patient and caregiver preferences. This article discusses common issues in the elderly with end-stage kidney disease, with particular emphasis on the impact of frailty and functional status, choice of dialysis modality and vascular access, and prognosis after dialysis initiation, to assist the nephrologist in making decisions regarding optimal care for this complex group of patients.

Conservative Care of the Elderly CKD Patient: A Practical Guide

Palliative care is a branch of medicine dedicated to the relief of symptoms experienced during the course of illness. Renal palliative medicine or kidney supportive care is an evolving branch of nephrology, which incorporates the principles of palliative care into the care of CKD and ESRD (dialysis, transplant, and conservatively managed) patients. Conservative (non-dialytic) management is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life. Patients with advanced CKD have a high symptom burden that often worsens before death. Palliative or supportive care by visiting nurses, palliative care programs, or knowledgeable CKD programs should be routine for conservatively managed CKD patients. Decision-making about dialysis or conservative management requires patients and families be given information on prognosis, quality of life on dialysis, and options for supportive care. Advance care planning is the process by which these issues can be explored. In addition to advance care planning, because patients with ESRD have a high symptom burden, this needs to be addressed. Patients with ESRD have a high symptom burden, which needs to be addressed in any treatment plan. Common symptoms include pain, fatigue, insomnia, pruritus, anorexia, and nausea. Symptoms appear to increase as the patient nears death, and this must be anticipated. Recommendations for management are discussed in the article. Hospice care should be offered to all patients who are expected to die within the next 6 months, and supportive care should be provided to all CKD patients managed conservatively or with dialysis.

Use of Erythropoietin-Stimulating Agents (ESA) in Patients With End-Stage Renal Failure Decided to Forego Dialysis: Palliative Perspective

Normochromic normocytic anemia is a common complication in chronic kidney disease (CKD) and is associated with many adverse clinical consequences. Erythropoiesis-stimulating agents (ESAs) act to replace endogenous erythropoietin for patients with end-stage renal disease having anemia. Today, ESAs remain the main tool for treating anemia associated with CKD. In current practice, the use of ESA is not limited to the patients on renal replacement therapy but has extended to nondialysis patients under palliative care (PC). Current evidence on ESA usage in patients with CKD decided to forego dialysis often have to take reference from studies conducted in other groups of patients with CKD, including pre-dialysis patients and those on renal replacement therapy. There is paucity of studies targeting use of ESAs in renal PC patients. Small-scale retrospective study in renal PC patients had suggested clinical advantage of ESAs in terms of hemoglobin improvement, reduction in fatigue, and hospitalization rate. With the expected growth in elderly patients with CKD decided to forego dialysis and manage conservatively, there remains an urgent need to call for large-scale prospective trial in exploring efficacy of ESAs in this population, targeting on quality of life and symptoms improvement outcome. This article also reviews the mechanism of action, pharmacology, adverse effects, and clinical trial evidence for ESA in patients with CKD under renal PC.

Communication Skills and Decision Making for Elderly Patients With Advanced Kidney Disease: A Guide for Nephrologists

Elderly patients comprise the most rapidly growing population initiating dialysis therapy and may derive particular benefit from comprehensive assessment of geriatric syndromes, coexisting comorbid conditions, and overall prognosis. Palliative care is a philosophy that aims to improve quality of life and assist with treatment decision making for patients with serious illness such as kidney disease. Palliative skills for the nephrology provider can aid in the care of these patients. This review provides nephrology providers with 4 primary palliative care skills to guide treatment decision making: (1) use prognostic tools to identify patients who may benefit from conservative management, (2) disclose prognostic information to patients who may not do well with dialysis therapy, (3) incorporate patient goals and values to outline a treatment plan, and (4) prepare patients and families for transitions and end of life.

[Conservative treatment, hemodialysis or peritoneal dialysis for elderly patients: The choice of treatment does not influence the survival]

Hemodialysis is the predominant replacement therapy in the 70 year-old French population (18% in peritoneal dialysis, 72% in hemodialysis from the REIN registry). Managing older patients reaching the end stage renal disease poses many ethical questions, since outcomes balanced regarding survival and quality of life. The aim of this study was to compare the survival of patients aged over 70 years according to the ESRD treatment choice: conservative treatment without dialysis (CT), hemodialysis (HD) and peritoneal dialysis (PD). We included all patients over 70 years reaching stade IV CKD integrated in a predialysis information program between 01/01/2005 and 31/12/2010. We compared their survival from the start of their program, in function of their treatment choice: HD, PD or CT. On this period, 148 patients were included, we excluded from analysis 17 patients who had a contraindication to PD, 26 patients who did not make a choice because their kidney function was stabilized, 4 patients lost to follow-up and 12 patients who died before the treatment choice. The average age was 79±6 years, 40% of patients were women, and the mean eGFR was 16±9 mL/min/1.73 m(2) at the entry in the program. Among the 89 patients, 21 choose CT (24%), 68 accepted dialysis (76%), including 48 HD (71%) and 20 PD (29%). No significant eGFR difference at the inclusion time between the groups. The time initiation of dialysis was significantly shorter in the PD group (146 days vs 442 in the HD group; P=0.004). Survival between the groups of patients who accepted or refused dialysis was not statistically different (749 days or 2 years in the HD + PD group vs 562 days, or 1 year and 6 months in the CT group; P=0.95) and between the HD group (760 days or 2 years and 2 months) and the PD group (343 days or 11 months; P=0.32). As measured from the time they entered in the predialysis program, the survival of older patients over 70 years does not seem to depend on their choice of treatment modality. Whether they accepted or refused dialysis, whatever their choice concerning hemodialysis or peritoneal dialysis, their survival was close to one year.

Stage 5-CKD under nephrology care: to dialyze or not to dialyze, that is the question

Appropriate timing of starting chronic dialysis in patients with advanced chronic kidney disease (CKD) under nephrology care still is undefined. We systematically reviewed the most recent studies that have compared outcomes of stage 5-CKD under conservative versus substitutive treatment. Eleven studies, most in elderly patients, were identified. Results indicate no advantage of dialysis over conservative management in terms of survival, hospitalization or quality of life. This information is integrated with a case report on a middle-aged CKD patient followed in our clinic who has remained for 15 years in stage 5 despite severe disease. The patient is a diabetic woman who underwent right nephrectomy in 1994 because of renal tuberculosis. In 1999, she commenced regular nephrology care in our clinic and, since 2000, when she was 53 years old, her estimated glomerular filtration rate (eGFR) has been ≤15 ml/min/1.73 m(2). Over the last decade, despite, several episodes of acute kidney injury and placement of permanent percutaneous nephrostomy in 2001, renal function has remained remarkably stable, though severely impaired (eGFR 7.7-5.6 ml/min/1.73 m(2)). Our systematic analysis of the literature and this case report highlight the need for further studies, not limited exclusively to elderly patients, to verify the efficacy of non-dialysis treatment in stage 5-CKD patients. Meanwhile, nephrologists may consider that their intervention can safely prolong for several years the dialysis-free condition in ESRD independently of age.

Palliative and end-of-life care issues in chronic kidney disease

PURPOSE OF REVIEW

Patients with progressive chronic kidney disease (CKD) have high morbidity, mortality, and symptom burden. Cardiovascular disease (CVD) and congestive heart failure (CHF) often contribute to these burdens and should be considered when providing recommendations for care. This review aims to summarize recent literature relevant to the provision of palliative and end-of-life care for patients with progressive CKD and specifically highlights issues relevant to those with CVD and CHF.

RECENT FINDINGS

Dialysis may not benefit older, frail patients with progressive CKD, especially those with other comorbidities. Patients managed conservatively (i.e., without dialysis) may live as long as patients who elect to start dialysis, with better preservation of function and quality of life and with fewer acute care admissions. Decisions regarding dialysis initiation should be made on an individual basis, keeping in mind each patient's goals, comorbidities, and underlying functional status. Conservative management of progressive kidney disease is frequently not offered but is likely to benefit many older, frail patients with comorbidities such as CHF and CVD.

SUMMARY

A palliative approach to the care of many patients with progressive CKD is essential to ensuring they receive appropriate quality care.

Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework

Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.

Diabetic Kidney Disease: A Syndrome Rather Than a Single Disease

The term "diabetic kidney" has recently been proposed to encompass the various lesions, involving all kidney structures that characterize protean kidney damage in patients with diabetes. While glomerular diseases may follow the stepwise progression that was described several decades ago, the tenet that proteinuria identifies diabetic nephropathy is disputed today and should be limited to glomerular lesions. Improvements in glycemic control may have contributed to a decrease in the prevalence of glomerular lesions, initially described as hallmarks of diabetic nephropathy, and revealed other types of renal damage, mainly related to vasculature and interstitium, and these types usually present with little or no proteinuria. Whilst glomerular damage is the hallmark of microvascular lesions, ischemic nephropathies, renal infarction, and cholesterol emboli syndrome are the result of macrovascular involvement, and the presence of underlying renal damage sets the stage for acute infections and drug-induced kidney injuries. Impairment of the phagocytic response can cause severe and unusual forms of acute and chronic pyelonephritis. It is thus concluded that screening for albuminuria, which is useful for detecting "glomerular diabetic nephropathy", does not identify all potential nephropathies in diabetes patients. As diabetes is a risk factor for all forms of kidney disease, diagnosis in diabetic patients should include the same combination of biochemical, clinical, and imaging tests as employed in non-diabetic subjects, but with the specific consideration that chronic kidney disease (CKD) may develop more rapidly and severely in diabetic patients.

System Dynamics Modeling Can be Leveraged to Predict Critical Care Pathways and Costs for End Stage Renal Disease: US Population to 2020

Background: End Stage Renal Disease (ESRD) accounts for 9% of Medicare spending, with the beneficiaries suffering from ESRD costing 7-9 times more than the average. This population is expected to continue to grow as a portion of Medicare beneficiaries. To provide clinicians and administrators with a greater understanding of the combined costs associated with the multiple critical care pathways for End Stage Renal Disease we have developed a model to predict ESRD populations through 2020. Methods: A system dynamics model was designed to project the prevalence and total costs of ESRD treatment for the United States through 2020. Incidence, transplant and mortality rates were modeled for 35 age and primary diagnosis subgroups coursing through different ESRD critical care pathways. Using a web interface that allows users to alter certain combinations of parameters, several demonstration analysis were run to predict the impact of three policy interventions on the future of ESRD care Results: The model was successfully calibrated against the output of United States Renal Data System's (USRDS) prior predictions and tested by comparing the output to historical data. Our model predicts that the ESRD patient population will continue to rise, with total prevalence increasing to 829,000 by 2020. This would be a 30% increase from the reported 2010 prevalence. Conclusions: Findings suggest that clinical care and policy changes can be leveraged to more effectively and efficiently manage the inevitable growth of ESRD patient populations. Patients can be shifted to more effective treatments, while planning integrating systems thinking can save Medicare's ESRD program billions over the next decade.

PAlliative Care in chronic Kidney diSease: the PACKS study--quality of life, decision making, costs and impact on carers in people managed without dialysis

Background

The number of patients with advanced chronic kidney disease opting for conservative management rather than dialysis is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice. This study will explore quality of life, symptoms, cognition, frailty, performance decision making, costs and impact on carers in people with advanced chronic kidney disease managed without dialysis and is funded by the National Institute of Health Research in the UK.

Methods

In this prospective, multicentre, longitudinal study, patients will be recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Carers will be asked to ‘opt-in’ with consent from patients. The approach includes longitudinal quantitative surveys of quality of life, symptoms, decision making and costs for patients and quality of life and costs for carers, with questionnaires administered quarterly over 12 months. Additionally, the decision making process will be explored via qualitative interviews with renal physicians/clinical nurse specialists.

Discussion

The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It will explore the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.

Optimizing outcomes in the elderly with end-stage renal disease--live long and prosper

BACKGROUND

The elderly form an expanding proportion of patients with chronic kidney disease and end-stage renal disease worldwide. The increased physiological frailty and functional morbidity associated with the aging process pose unique challenges when planning optimal management of an older patient needing renal replacement therapy (RRT).

AIMS

This position paper discusses current evidence regarding the optimal management of end-stage renal disease in the elderly with an emphasis on hemodialysis since it is the most common modality used in older patients. Further research is needed to define relevant patient-reported outcome measures for end-stage renal disease including functional assessments and psychological impacts of various forms of RRT. For those older patients who have opted for dialysis treatment, it is important to study the strategies that encourage greater uptake of home-based dialysis therapies and optimal vascular access.

CONCLUSIONS

The management of advanced chronic kidney disease in the elderly can be challenging but also extremely rewarding. The key issue is adopting a patient-focused and individualized approach that seeks to achieve the best outcomes based on a comprehensive holistic assessment of what is important to the patient.

The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia

The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.

Establishing a supportive care register improves end-of-life care for patients with advanced chronic kidney disease

BACKGROUND

End-of-life care for patients with advanced chronic kidney disease (CKD) is recognised as an important area for improvement. These patients have a significant mortality and, although some is unpredictable, there is a role for the nephrology multi-disciplinary team (MDT) and palliative care physicians to engage in advance care planning and support patients to discuss their preferences.

METHODS

Retrospective and prospective data were obtained to conduct a comparison observational study to assess the impact of introducing a supportive care register on the end-of-life care for patients with advanced CKD. An electronic supportive care register was implemented. This required a programme of multi-disciplinary staff education, collaborative working with Palliative Care to establish renal-specific protocols and dissemination activities. The impact of the intervention was assessed by analysing all deaths in two six-month periods where all those with an eGFR <15 ml/min/1.73 m(2) at the time of their death were included.

RESULTS

A total of 91 patients were included. Post-intervention, there was a 25.4% (95% CI: 6.5-44.3%, p = 0.008) improvement in patients having a documented discussion about end-of-life planning. There was also a 19.7% (95% CI: 4.0-35.5%, p = 0.01) improvement in establishing the place of death. All patients who expressed a preferred place of death died there. The intervention increased engagement with the wider MDT and led to significant improvements in access to specialist palliative care services.

CONCLUSIONS

These results show that the interventions implemented to introduce a supportive care register resulted in meaningful improvements to the end-of-life care for patients in our region with advanced CKD. © 2015 S. Karger AG, Basel.

Should dialysis be offered to all elderly patients?

Nephrologist are often faced with the question of the appropriate initiation and withdrawal from dialysis. Many clinicians feel that patient should be offered dialysis when they have ESRD regardless of the potential risks vs. benefits. My position in this debate is that nephrologists have the obligation to order treatments that are indicated and effective for their patients and will provide more benefit that harm. They should not order dialysis in patient that are not likely to benefit from the treatment. Patients have the right to refuse treatments but not the right to demand that a clinician order an ineffective treatment. Shared decision making is the key principle in deciding on the initiation and withdrawal from dialysis. The national guideline; Shared Decision Making: The Appropriate Initiation and Withdrawal from Dialysis supports this approach.

CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life

BACKGROUND AND OBJECTIVES

Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic.

RESULTS

Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL.

CONCLUSIONS

Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.

How to integrate predictions in outcomes in planning clinical care

BACKGROUND

The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason, accurate predictive information related to the progression into ESRD, mortality, and functional decline is critical to allow for optimal shared decision making (SDM).

SUMMARY

This review will assess the current literature on the methodologies for the estimation of prognosis and prognostic tools developed for CKD. A practical clinical approach is discussed that involves the estimation of prognosis and integration of prognosis into SDM.

KEY MESSAGE

There are validated, easy-to-use prognostic tools that help clinicians engage in effective shared decision making with their CKD patients and family.

The Elderly are Different: Initiating Dialysis in Frail Geriatric Patients

Decisions and discussions about the initiation of dialysis in the elderly are often challenging because of the high prevalence of comorbidities and frailty in this population. Mortality is high, functional decline is likely, and quality of life tends to be lower in the elderly on dialysis. It is thus important to counsel these patients on the risks, benefits, and burdens of dialysis to assist them in making an informed choice that is in line with their goals, preferences, and expectations. For some patients, dialysis may be a desirable choice. For others, the alternative of palliative care may provide a more favorable balance of benefits versus burdens. Elderly patients who choose to proceed with dialysis often benefit from an interdisciplinary team that helps to manage and monitor their health status, while maximizing the benefits of treatment and decreasing its potential harms. These goals can be promoted by effective communication and through individualized decisions about vascular access, medication choices, and dietary limitations. Finally, close monitoring of functional status will help to determine whether dialysis remains in a patient's best interest and when alternatives should be offered.

Understanding by older patients of dialysis and conservative management for chronic kidney failure

Background

Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units.

Study Design

Qualitative study with semistructured interviews.

Settings & Participants

Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management.

Methodology

Semistructured interviews audiorecorded and transcribed verbatim.

Analytical Approach

Data were analyzed using thematic analysis.

Results

42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision.

Limitations

Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited.

Conclusions

Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.

The right patient, the right treatment, the right access and the right time

As the incidence of CKD increases, so will the ESRD population. Pre-ESRD care, including early referral to nephrology and patient education, enables patients and providers working together to determine which therapy modality is best suited for their individualized needs: conservative therapy, kidney transplant, hemodialysis, or peritoneal dialysis. Differentiating the therapy modality should be based on many factors and not solely based on outcome data. Acknowledging that there is no "one-size-fits-all" therapy modality allows the patient and the interdisciplinary team to ensure that the appropriate access is chosen at the appropriate time. Lastly, the timing of initiation is paramount for improving patient outcomes, including less central venous catheter placement in incident hemodialysis and more planned arteriovenous accesses, improved quality of life, less hospitalization time, and reduced costs.

Decision making in elderly patients with advanced kidney disease

Because the fastest-growing group of patients undergoing dialysis is older than 75 years, geriatricians will be more involved in decisions regarding the appropriate treatment of end-stage renal disease. A thoughtful approach to shared decision making regarding dialysis or nondialysis medical therapy (NDMT) includes consideration of medical indications, patient preferences, quality of life, and contextual features. Determination of prognosis and expected performance on dialysis based on disease trajectories and assessment of functional age should be shared with patients and families. The Renal Physician Association's guidelines on shared decision making in dialysis offer recommendations to help with dialysis or NDMT decisions.

Decision-making in patients with cancer and kidney disease

Thoughtful decision-making in a patient with cancer and kidney disease requires a comprehensive discussion of prognosis and therapy options for both conditions framed by the individual's preferences and goals of care. An estimate of overall prognosis is generated that includes the patient's clinical presentation and parameters associated with adverse outcomes, such as age, performance status, frailty, malnutrition, and comorbidities. Empathic communication of this information using a shared decision-making approach can lead to an informed decision that respects patient autonomy and is consistent with the patient's "big-picture" goals and personal values.

Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis

The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.

Outcomes in older adults with stage 5 chronic kidney disease: comparison of peritoneal dialysis and conservative management

BACKGROUND

Data on the outcomes of older adults receiving peritoneal dialysis (PD), especially those who are dependent and have multiple comorbidities, are scarce.

METHODS

In a retrospective cohort study, we compared older adults (≥65 years) with stage 5 chronic kidney disease receiving PD (PD group) with those receiving conservative management (conservative group). Baseline characteristics (demographics and clinical, functional, socioeconomic, and laboratory parameters) were collected, and study outcomes (patient survival, emergency hospitalization, institutionalization, and palliative and end-of-life care) were compared between groups.

RESULTS

We included 199 eligible participants aged 65-90 years (mean ± standard deviation 73.8 ± 5.4 years; 157 in the PD group and 42 in the conservative group). The PD group had a longer survival (median [interquartile range]: 3.75 [2.49-5.25] vs 2.35 [1.13-3.71] years, p < .001), lower emergency hospitalization rates (1.63 [0.82-2.92] vs 3.51 [1.06-7.16] per person-year, p < .01) and hospital days (16.17 [6.29-43.32] vs 38.01 [6.75-76.56] days per person-year, p = .03), and no increased risk of institutionalization compared with the conservative group. Age (hazard ratio [HR] for 1-year increase 1.06, 95% confidence interval [CI] 1.02-1.10), modified Charlson's Comorbidity Index (HR 1.36, 95% CI 1.18-1.56), impairment in basic activities of daily living (HR 2.11, 95% CI 1.28-3.46), and emergency dialysis (HR 1.67, 95% CI 1.11-2.53) were independent predictors of mortality in the PD group.

CONCLUSION

PD is a viable treatment option in older adults with stage 5 chronic kidney disease. Age alone should not preclude dialysis. Comprehensive geriatric assessment can prognosticate and facilitate shared decision making to commence dialysis in older adults.

Recent insights into life expectancy with and without dialysis

PURPOSE OF REVIEW

Elderly patients comprise the fastest growing population initiating dialysis and also experience the worst outcomes, including increased mortality, loss of functional status, and impaired quality of life. Nephrologists are often challenged with how best to engage in dialysis decision-making discussions within this population. Prognostication tools can assist nephrologists in engaging in these discussions, especially in patients for whom survival benefits may be outweighed by the burdens of treatment.

RECENT FINDINGS

This review includes the latest research in the survival of elderly patients with and without dialysis; prognostic factors associated with renal progression and survival; and integrative prognostic models to predict both short-term and long-term prognosis. The concept of kidney illness disease trajectory is defined with important outcomes including survival, health-related quality of life, and symptoms with and without dialysis. This prognostic information will then be integrated into an individualized approach to shared decision-making regarding treatment decision-making.(Figure is included in full-text article.)

SUMMARY

Treatment decision-making for elderly patients with advanced kidney disease necessitates an active process between nephrologist and patient, incorporating medical information as well as patient preferences. Prognostic information and observational data can facilitate nephrologists' ability to foresee and foretell the illness trajectory both with and without dialysis, further guiding these conversations.

Ageism vs. the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients

Purpose

Treatment intensity for elderly patients with end-stage renal disease has escalated beyond population growth. Ageism seems to have given way to a powerful imperative to treat patients irrespective of age, prognosis, or functional status. Hemodialysis (HD) is a prime example of this trend. Recent articles have questioned this practice. This paper aims to identify existing pre-synthesized evidence on HD in the very elderly and frame it from the perspective of a clinician who needs to involve their patient in a treatment decision.

Patients and methods

A comprehensive search of several databases from January 2002 to August 2012 was conducted for systematic reviews of clinical and economic outcomes of HD in the elderly. We also contacted experts to identify additional references. We applied the rigorous framework of decisional factors of the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) to evaluate the quality of evidence and strength of recommendations.

Results

We found nine eligible systematic reviews. The quality of the evidence to support the current recommendation of HD initiation for most very elderly patients is very low. There is significant uncertainty in the balance of benefits and risks, patient preference, and whether default HD in this patient population is a wise use of resources.

Conclusion

Following the GRADE framework, recommendation for HD in this population would be weak. This means it should not be considered standard of care and should only be started based on the well-informed patient’s values and preferences. More studies are needed to delineate the true treatment effect and to guide future practice and policy.

Trajectory of quality of life for poor prognosis stage 5D chronic kidney disease with and without dialysis

BACKGROUND

Renal replacement therapy (RRT) has not always been shown to benefit end-stage renal failure patients who are elderly or have multiple comorbidities in terms of survival or symptom control. Conservative management may be a viable alternative offering comparable health-related quality of life.

METHODS

This is a prospective observational study of 101 patients who reached an estimated glomerular filtration rate of 8-12 ml/min and were either ≥75 years old or had an age-adjusted Charlson Comorbidity Index ≥8. Patients were all initially on conservative management; 38 later commenced renal replacement therapy while the rest remained conservatively managed. The Kidney Disease Quality of Life-Short Form was assessed at baseline and various scheduled time points over 24 months. The mixed model methodology was used to estimate the quality of life patterns and adjust for covariates.

RESULTS

In the conservative management group, the Physical Component Summary and Mental Component Summary scores were stable and showed no significantly different trajectories from the RRT group (both p > 0.05). Though RRT was associated with an improvement in the Cognitive Function Scale score, it was also associated with worse scores on the Effect of Kidney Disease and Burden of Kidney Disease Scale scores.

CONCLUSIONS

RRT does not improve health-related quality of life of end-stage kidney failure patients who are elderly or have a high comorbidity burden.

A prospective, multicenter, phase 2 study of imatinib mesylate in korean patients with metastatic or unresectable gastrointestinal stromal tumor

OBJECTIVES

This prospective, multicenter, phase 2 study evaluated the efficacy and safety of imatinib mesylate and assessed KIT and PDGFRA gene mutation status in Korean patients with gastrointestinal stromal tumors (GISTs).

METHODS

Forty-seven patients with pathologically proven KIT-positive metastatic or unresectable GISTs were accrued from eight institutions in Korea. Imatinib was administered orally at 400 mg once daily. In case of disease progression, the dose was escalated to 600 mg once daily, then 400 mg twice daily. KIT and PDGFRA mutations were analyzed in 29 of the 47 patients.

RESULTS

Imatinib produced partial responses in 30 patients (63.8%; 95% confidence interval, 50.1-77.6%) and stable disease in 13 patients (27.7%). The median time to response was 2.6 months (range, 1.0-6.2 months). With a median follow-up of 62 months (range, 32-67 months), 4-year progression-free survival and overall survival rates were 50 and 65%, respectively. The most common adverse events were anemia, neutropenia, edema, and skin rash (predominantly of grade 1-2). There were no treatment-related deaths. In the subset evaluated for mutational status, 24 patients (82.8%) had KIT exon 11 mutations and 1 (3.4%) had a KIT exon 9 mutation.

CONCLUSIONS

Imatinib is effective and safe in Korean patients with metastatic or unresectable GIST.