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

Stage 5 Chronic Kidney Disease: Epidemiological Analysis in a NorthEastern District of Italy Focusing on Access to Nephrological Care

BACKGROUND

We conducted a retrospective epidemiological study about the prevalence of stage 5 chronic kidney disease (CKD) in a high-income district, comparing some demographic characteristics and outcomes of those patients who had nephrological consultations and those who had not.

RESULTS

In a district of 400,000 adult subjects in 2020, 925 patients had an estimated glomerular filtration rate (eGFR) under 15 mL/min and CKD. In the same period, 747 (80.4%) patients were assessed by nephrologists, while 178 (19.6%) were not. Age (88 vs. 75, p < 0.0001), female gender (66.3% vs. 47%, p < 0.001), and eGFR (12 vs. 9 mL/min, p < 0.001) were significantly different in the patients assessed by a nephrologist as compared those who did not have nephrological care. Furthermore, unfollowed CKD patients had a significantly higher death rate, 83.1% versus 14.3% (p < 0.0001).

CONCLUSIONS

About 20% of ESKD patients did not receive a nephrologist consultation. Older people and women were more likely not to be referred to nephrology clinics. Unfollowed patients with stage 5 CKD had a significantly higher death rate.

Differences in the epidemiology, management and outcomes of kidney disease in men and women

Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.

Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

INTRODUCTION

Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.

METHODS

We evaluated sex as the variable of interest in a health care-based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.

RESULTS

We identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.

CONCLUSIONS

There were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.

Increasing numbers and improved overall survival of patients on kidney replacement therapy over the last decade in Europe: an ERA Registry study

INTRODUCTION

The aim of this study was to describe the trends in the incidence, prevalence and survival of patients on kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) across Europe from 2008 to 2017.

METHODS

Data from renal registries in 9 countries and 16 regions that provided individual patient data to the ERA Registry from 2008 to 2017 were included. These registries cover 34% of the general population in Europe. Crude and standardized incidence and prevalence per million population (pmp) were determined. Trends over time were studied using Joinpoint regression. Survival probabilities were estimated using Kaplan-Meier analysis and hazard ratios (HRs) using Cox regression analysis.

RESULTS

The standardized incidence of KRT was stable (annual percentage change [APC]: -1.48 [-3.15; 0.21]) from 2008 (146.0 pmp) to 2011 (141.6 pmp), followed by a slight increase (APC: 1.01 [0.43; 1.60]) to 148.0 pmp in 2017, although trends in incidence varied across countries. This increase was primarily due to a rise in the incidence of KRT in men older than 65 years. Moreover, as a cause of kidney failure, diabetes mellitus is increasing. The standardized prevalence increased from 2008 (990.0 pmp) to 2017 (1166.8 pmp) (APC: 1.82 [1.75; 1.89]). Patient survival on KRT improved in the time period 2011-2013 compared with 2008-2010 (adjusted HR: 0.94 [0.93; 0.95).

CONCLUSION

This study showed an overall increase in the incidence and prevalence of KRT for ESKD as well as an increase in the KRT patient survival over the last decade in Europe.

The Other Way Around: Living With Chronic Kidney Disease From the Perspective of Men

A wealth of evidence has suggested sex (biological) and gender (sociocultural) differences in the prevalence, progression, and outcomes of persons with chronic kidney disease. Much of this evidence tends to emphasize differences in which women are disadvantaged, and less attention is paid to findings in which women are better off or similar to men. However, gender medicine recognizes that men and women have different disease determinants, presentation, and attitudes, and it pertains to both sexes. In this review, we revisit chronic kidney disease through the perspective of men, and illustrate a population segment at need of stringent preventative and management strategies.

Sex-Based Differences in Risk Factors and Complications of Chronic Kidney Disease

Globally, females are ∼30% more likely to have pre-dialysis chronic kidney disease (CKD) than males for reasons that are not fully understood. CKD is associated with numerous adverse health outcomes which makes understanding and working to eradicating sex based disparities in CKD prevalence essential. This review maps both what is known, and what is unknown, about the way sex and gender impacts (1) the epidemiology and risk factors for CKD including age, diabetes, hypertension, obesity, smoking, and cerebrovascular disease, and (2) the complications from CKD including kidney disease progression, cardiovascular disease, CKD mineral and bone disorders, anaemia, quality-of-life, cancer and mortality. This mapping can be used to guide future research.

Kidney Function, Kidney Replacement Therapy, and Mortality in Men and Women

Introduction

Women are more likely to have chronic kidney disease (CKD), compared with men, yet they are less likely to receive dialysis. Whether this sex disparity, which has predominantly been observed in nephrology-referred or CKD-specific cohorts so far, has a biological root cause remains unclear.

Methods

We extracted general population data from the Stockholm CREAtinine Measurements project (SCREAM) (N = 496,097 participants, 45.5% men, 54.5% women). We used Cox regression to model male-to-female cause-specific hazard ratios (csHRs) for the competing events kidney replacement therapy (KRT, by dialysis or transplantation) and pre-KRT death, adjusted for baseline age, baseline kidney function (assessed via estimated glomerular filtration rate [eGFR] and eGFR slope), and comorbidities. Furthermore, we modeled sex-specific all-cause mortality by eGFR, again adjusted for age, eGFR slope, and comorbidities at baseline.

Results

Compared with women, men were significantly more likely to receive KRT (fully adjusted male-to-female csHR for KRT 1.41 [95% CI 1.13–1.76]) but also more likely to experience pre-KRT death (csHR 1.36 [95% CI 1.33–1.38]). Differences between men and women regarding all-cause mortality by eGFR indicated a higher mortality in men at low eGFR values.

Conclusion

Our data show that sex differences in CKD outcomes persist even after controlling for important comorbidities and kidney function at baseline. While future studies with a wider range of biological factors are warranted, these data suggest that nonbiological factors may be more important in explaining existing sex disparities in CKD progression and therapy.

Sex-Specific Differences in Mortality and Incident Dialysis in the Chronic Kidney Disease Outcomes and Practice Patterns Study

Introduction

More men than women start kidney replacement therapy (KRT) although the prevalence of chronic kidney disease (CKD) is higher in women than men. We therefore aimed at analyzing sex-specific differences in clinical outcomes among 8237 individuals with CKD in stages 3 to 5 from Brazil, France, Germany, and the United States participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps).

Methods

Fine and Gray models, evaluating the effect of sex on time to events, were adjusted for age, Black race (model A); plus diabetes, cardiovascular disease, albuminuria (model B); plus estimated glomerular filtration rate (eGFR) slope during the first 12 months after enrollment and first eGFR after enrollment (model C).

Results

There were more men than women at baseline (58% vs. 42%), men were younger than women, and men had higher eGFR (28.9 ± 11.5 vs. 27.0 ± 10.8 ml/min per 1.73 m²). Over a median follow-up of 2.7 and 2.5 years for men and women, respectively, the crude dialysis initiation and pre-emptive transplantation rates were higher in men whereas that of pre-KRT death was more similar. The adjusted subdistribution hazard ratios (SHRs) between men versus women for dialysis were 1.51 (1.27–1.80) (model A), 1.32 (1.10–1.59) (model B), and 1.50 (1.25–1.80) (model C); for pre-KRT death, were 1.25 (1.02–1.54) (model A), 1.14 (0.92–1.40) (model B), and 1.15 (0.93–1.42) (model C); for transplantation, were 1.31 (0.73–2.36) (model A), 1.44 (0.76–2.74) (model B), and 1.53 (0.79–2.94) (model C).

Conclusion

Men had a higher probability of commencing dialysis before death, unexplained by CKD progression alone. Although the causal mechanisms are uncertain, this finding helps interpret the preponderance of men in the dialysis population.

Palliative Care in Patients with End-Stage Renal Disease: A Meta Synthesis

End-stage renal disease is the last stage of chronic kidney disease and is associated with a decreased quality of life and life expectancy. This study aimed to explore palliative care with end-stage renal disease. Qualitative meta-synthesis was used as the study design. The search was performed for qualitative studies published until June 2021 and uses reciprocal translation and synthesis of in vivo and imported concepts. Five themes were included: Struggling to face the disease, experiencing deterioration, overcoming the challenges of dialysis, leading to a positive outlook, and preparing for the end of life. In facing chronic disease with life-limiting potential, patients experienced some negative feelings and deterioration in their quality of life. Adaptation to the disease then leads patients to a better outlook through increased spirituality and social status. Furthermore, by accepting the present condition, they started to prepare for the future. Increasing awareness of mortality leads them to discuss advance care (ACP) planning with healthcare professionals and families.

The validity of Dutch health claims data for identifying patients with chronic kidney disease: a hospital-based study in the Netherlands

BACKGROUND

Health claims data may be an efficient and easily accessible source to study chronic kidney disease (CKD) prevalence in a nationwide population. Our aim was to study Dutch claims data for their ability to identify CKD patients in different subgroups.

METHODS

From a laboratory database, we selected 24 895 adults with at least one creatinine measurement in 2014 ordered at an outpatient clinic. Of these, 15 805 had ≥2 creatinine measurements at least 3 months apart and could be assessed for the chronicity criterion. We estimated the validity of a claim-based diagnosis of CKD and advanced CKD. The estimated glomerular filtration rate (eGFR)-based definitions for CKD (eGFR < 60 mL/min/1.73 m2) and advanced CKD (eGFR < 30 mL/min/1.73 m2) satisfying and not satisfying the chronicity criterion served as reference group. Analyses were stratified by age and sex.

RESULTS

In general, sensitivity of claims data was highest in the population with the chronicity criterion as reference group. Sensitivity was higher in advanced CKD patients than in CKD patients {51% [95% confidence interval (CI) 47-56%] versus 27% [95% CI 25-28%]}. Furthermore, sensitivity was higher in young versus elderly patients. In patients with advanced CKD, sensitivity was 72% (95% CI 62-83%) for patients aged 20-59 years and 43% (95% CI 38-49%) in patients ≥75 years. The specificity of CKD and advanced CKD was ≥99%. Positive predictive values ranged from 72% to 99% and negative predictive values ranged from 40% to 100%.

CONCLUSION

When using health claims data for the estimation of CKD prevalence, it is important to take into account the characteristics of the population at hand. The younger the subjects and the more advanced the stage of CKD the higher the sensitivity of such data. Understanding which patients are selected using health claims data is crucial for a correct interpretation of study results.

CKD Progression and Mortality Among Men and Women: A Nationwide Study in Sweden

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) is a global health problem with increasing prevalence. Several sex-specific differences have been reported for disease progression and mortality. Selection and survival bias might have influenced the results of previous cohort studies. The objective of this study was to investigate sex-specific differences of CKD progression and mortality among patients with CKD not receiving maintenance dialysis.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

Adult patients with incident CKD glomerular filtration rate categories 3b to 5 (G3b-G5) identified between 2010 and 2018 within the nationwide Swedish Renal Registry-CKD (SRR-CKD).

EXPOSURE

Sex.

OUTCOMES

Time to CKD progression (defined as a change of at least 1 CKD stage or initiation of kidney replacement therapy [KRT]) or death. Repeated assessments of estimated glomerular filtration rate (eGFR).

ANALYTICAL APPROACH

CKD progression and mortality before KRT were assessed by the cumulative incidence function methods and Fine and Gray models, with death handled as a competing event. Sex differences in eGFR slope were estimated using mixed effects linear regression models.

RESULTS

7,388 patients with incident CKD G3b, 18,282 with incident CKD G4, and 9,410 with incident CKD G5 were identified. Overall, 19.6 (95% CI, 19.2-20.0) patients per 100 patient-years progressed, and 10.1 (95% CI, 9.9-10.3) patients per 100 person-years died. Women had a lower risk of CKD progression (subhazard ratio [SHR], 0.88 [95% CI, 0.85-0.92]), and a lower all-cause (SHR, 0.90 [95% CI, 0.85-0.94]) and cardiovascular (SHR, 0.83 [95% CI, 0.76-0.90]) mortality risk. Risk factors related to a steeper decline in eGFR included age, sex, albuminuria, and type of primary kidney disease.

LIMITATIONS

Incomplete data for outpatient visits and laboratory measurements and regional differences in reporting.

CONCLUSIONS

Compared to women, men had a higher rate of all-cause and cardiovascular mortality, an increased risk of CKD progression, and a steeper decline in eGFR.

Novel conservative management of chronic kidney disease via dialysis-free interventions

PURPOSE OF REVIEW

In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population.

RECENT FINDINGS

The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden.

SUMMARY

As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.

The impact of hypertension on chronic kidney disease and end-stage renal disease is greater in men than women: a systematic review and meta-analysis

BACKGROUND

Hypertension (HTN) is an established risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). Whether sex differences in the effect of HTN on CKD and ESRD incidence exist remains unclear. This systematic review and meta-analysis was conducted to evaluate the relative impact of HTN on CKD and ESRD risk in women compared with men.

METHODS

We systematically searched Embase and PubMed for cohort studies until 24 July 2020. Studies were selected if they reported a sex-specific association between systolic blood pressure (SBP) and CKD or ESRD. Random effects meta-analyses with inverse variance weighting were used to pool sex-specific relative risks (RRs) and the women-to-men ratio of RRs (the RRR) for incident CKD and ESRD.

RESULTS

Data from six cohorts, including 2,382,712 individuals and 6856 incident CKD events, and 833 ESRD events, were included in the meta-analysis. The RR for incident CKD or ESRD associated with HTN (SBP ≥140 mmHg) versus ideal BP (SBP < 120 mmHg) was 1.56 (95% CI, 1.39-1.75) in women and 2.06 (95% CI, 1.64-2.60) in men. The RR for incident CKD or ESRD was 23% lower in women than in men RRR 0.77 [95% CI, 0.63-0.95] with no significant heterogeneity between studies (p-value for Q test = 0.507, I² = 17.7%).

CONCLUSION

HTN confers about a fifth lower excess risk of incident CKD or ESRD in women than men. Sex differences in onset, duration, and severity of some risk factors, such as albuminuria, diabetes, cardiovascular disease, obesity, and socioeconomic status, may explain part of the excess risk in men. Another explanation could be that women might be under-diagnosed and less likely to initiate dialysis. Future studies are needed to demonstrate the mechanisms responsible for the observed sex difference.

Sex and gender: modifiers of health, disease, and medicine

Clinicians can encounter sex and gender disparities in diagnostic and therapeutic responses. These disparities are noted in epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment. This Review discusses the fundamental influences of sex and gender as modifiers of the major causes of death and morbidity. We articulate how the genetic, epigenetic, and hormonal influences of biological sex influence physiology and disease, and how the social constructs of gender affect the behaviour of the community, clinicians, and patients in the health-care system and interact with pathobiology. We aim to guide clinicians and researchers to consider sex and gender in their approach to diagnosis, prevention, and treatment of diseases as a necessary and fundamental step towards precision medicine, which will benefit men's and women's health.

Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomes

A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.

Discussions during shared decision-making in older adults with advanced renal disease: a scoping review

OBJECTIVES

This review summarises the information available for clinicians counselling older patients with kidney failure about treatment options, focusing on prognosis, quality of life, the lived experiences of treatment and the information needs of older adults.

DESIGN

We followed the Joanna Briggs Institute Methodology for Scoping Reviews. The final report conforms to the PRISMA-ScR guidelines.

DATA SOURCES

PubMed, PsycINFO, CINAHL, Embase, Scopus, Web of Science, TRIP and online repositories (for dissertations, guidelines and recommendations from national renal associations).

ELIGIBILITY CRITERIA FOR INCLUSION

Articles in English studying older adults with advanced kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m²); published between January 2000 and August 2018. Articles not addressing older patients separately or those comparing between dialysis modalities were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened articles for inclusion and grouped them by topic as per the objectives above. Quantitative data were presented as tables and charts; qualitative themes were identified and described.

RESULTS

248 articles were included after screening 15 445 initial results. We summarised prognostic scores and compared dialysis and non-dialytic care. We highlighted potentially modifiable factors affecting quality of life. From reports of the lived experiences, we documented the effects of symptoms, of ageing, the feelings of disempowerment and the need for adaptation. Exploration of information needs suggested that patients want to participate in decision-making and need information, in simple terms, about survival and non-survival outcomes.

CONCLUSION

When discussing treatment options, validated prognostic scores are useful. Older patients with multiple comorbidities do not do well with dialysis. The modifiable factors contributing to the low quality of life in this cohort deserve attention. Older patients suffer a high symptom burden and functional deterioration; they have to cope with significant life changes and feelings of disempowerment. They desire greater involvement and more information about illness, symptoms and what to expect with treatment.

Sex Differences in Kidney Replacement Therapy Initiation and Maintenance

BACKGROUND AND OBJECTIVES

More men than women undergo kidney replacement therapy (KRT) despite a larger number of women being affected by CKD. The aim of this multinational European study was to explore whether there might be historic and geographic trends in sex-specific incidence and prevalence of various KRT modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We assessed sex-specific differences in KRT incidence and prevalence using data from nine countries reporting to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry for at least 40 years, during the period 1965-2015. Sex distribution data were compared with the European general population (Eurostat). Statistical methodology included basic descriptive statistics, incidence and prevalence calculations per million population (pmp), as well as their male-to-female ratios. Analyses were stratified by age group and diabetic status.

RESULTS

We analyzed data from 230,378 patients receiving KRT (38% women). For all KRT modalities, the incidence and prevalence rates were consistently higher in men than women. For example, the KRT incidence increased from 8 pmp in 1965-1974 to 98 pmp in 2005-2015 in women, whereas it rose from 12 to 173 pmp in men during the same period. Male-to-female ratios, calculated for incident and prevalent KRT patients, increased with age (range 1.2-2.4), showing consistency over decades and for individual countries, despite marked changes in primary kidney disease (diabetes more prevalent than glomerulonephritis in recent decades). The proportion of kidney transplants decreased less with age in incident and prevalent men compared with women on KRT. Stratified analysis of patients who were diabetic versus nondiabetic revealed that the male-to-female ratio was markedly higher for kidney transplantation in patients with diabetes.

CONCLUSIONS

Since the beginning of KRT programs reporting to the ERA-EDTA Registry since the 1960s, fewer women than men have received KRT. The relative difference between men and women initiating and undergoing KRT has remained consistent over the last five decades and in all studied countries.

Health-related quality of life and well-being in people over 75 years of age with end-stage kidney disease managed with dialysis or comprehensive conservative care: a cross-sectional study in the UK and Australia

OBJECTIVE

To measure health-related quality of life (HRQoL) and well-being in older people with end-stage kidney disease (ESKD) and to determine the association between treatment type and sociodemographic characteristics on these outcome measures. In addition, to assess the convergent validity between the HRQoL and well-being measure and their feasibility and acceptability in this population.

DESIGN

Prospective cross-sectional study.

SETTING

Three renal units in the UK and Australia.

PARTICIPANTS

129 patients with ESKD managed with dialysis or with an estimated glomerular filtration ≤10 mL/min/1.73 m² and managed with comprehensive conservative, non-dialytic care.

OUTCOME MEASURES

HRQoL and well-being were assessed using Short-Form six dimensions (SF-6D, 0-1 scale); Kidney Disease Quality of Life (KDQOL-36) (0-100 scale) and Investigating Choice Experiments Capability Measure-Older people (ICECAP-O, 0-1 scale). Linear regression assessed associations between treatment, HRQoL and well-being. Pearson's correlation coefficient assessed convergent validity between instruments.

RESULTS

Median age of 81 years (IQR 78-85), 65% males; 83 (64%) were managed with dialysis and 46 (36%) with conservative care. When adjusted for treatment type and sociodemographic variables, those managed on dialysis reported lower mean SF-6D utility (-0.05, 95% CI -0.12 to 0.01); lower KDQOL Physical Component Summary score (-3.17, 95% CI -7.61 to 1.27); lower Mental Component Summary score (-2.41, 95% CI -7.66 to 2.84); lower quality of life due to burden (-28.59, 95% CI -41.77 to -15.42); symptoms (-5.93, 95% CI -14.61 to 2.73) and effects of kidney disease (-16.49, 95% CI -25.98 to -6.99) and lower overall ICECAP-O well-being (-0.07, 95% CI -0.16 to 0.02) than those managed conservatively. Correlation between ICECAP-O well-being and SF-6D utility scores was strong overall, 0.65 (p<0.001), but weak to moderate at domain level.

CONCLUSIONS

Older people on dialysis report significantly higher burden and effects of kidney disease than those on conservative care. Lower HRQoL and well-being may be associated with dialysis treatment and should inform shared decision-making about treatment options.

TRIAL REGISTRATION NUMBER

UK (IRAS project ID: 134360andREC reference 14/LO/0291) and Australia (R20140203 HREC/14/RAH/36).

Valoración de la elección de tratamiento conservador en la enfermedad renal crónica

Introducción: El tratamiento conservador es una opción de tratamiento en la enfermedad renal crónica. Esta elección es decisión del paciente y/o familia. Objetivo: Analizar el proceso de elección de tratamiento conservador, identificar el perfil de paciente que lo elige, su supervivencia y quien comunica la elección. Material y Método: Estudio observacional, retrospectivo. Se incluyeron pacientes que eligieron tratamiento conservador entre 2010-2017. Los datos se obtuvieron de los registros de enfermería en historia clínica. Se recogieron variables demográficas, supervivencia, Índice de Comorbilidad de Charlson, índice de Barthel y valores de los pacientes utilizando la herramienta Tarjetas de valores. Resultados: Se estudiaron 95 pacientes: 41,05% hombres, edad media 82,36±9 años, 27,37% institucionalizados. La familia comunicó la elección en el 62,11% de los casos. La media del filtrado glomerular al inicio de la información fue 11,53±2,73ml/min, mediana del Charlson 8(13-3), Barthel 55 (100-0) puntos. En el proceso de evidenciar valores, la tarjeta más elegida fue “personal sanitario responsable del tratamiento”. La supervivencia media fue 496,19 días±553,8. Viven menos los hombres y los institucionalizados, sin diferencia significativa. El riesgo de muerte es mayor, al aumentar el Charlson y disminuir el filtrado glomerular (p=0,01). La familia comunicó la elección de seguir tratamiento conservador en el 62,11% de los casos. Conclusiones: El paciente que opta por tratamiento conservador es, una persona anciana, dependiente, con comorbilidades, supervivencia media en torno a 18 meses y en más de la mitad de los casos es la familia quien comunica la decisión de optar por ese tratamiento.

Sex-Related Disparities in CKD Progression

BACKGROUND

In the United States, incidence of ESRD is 1.5 times higher in men than in women, despite men's lower prevalence of CKD. Prior studies, limited by inclusion of small percentages of minorities and other factors, suggested that men have more rapid CKD progression, but this finding has been inconsistent.

METHODS

In our prospective investigation of sex differences in CKD progression, we used data from 3939 adults (1778 women and 2161 men) enrolled in the Chronic Renal Insufficiency Cohort Study, a large, diverse CKD cohort. We evaluated associations between sex (women versus men) and outcomes, specifically incident ESRD (defined as undergoing dialysis or a kidney transplant), 50% eGFR decline from baseline, incident CKD stage 5 (eGFR<15 ml/min per 1.73 m²), eGFR slope, and all-cause death.

RESULTS

Participants' mean age was 58 years at study entry; 42% were non-Hispanic black, and 13% were Hispanic. During median follow-up of 6.9 years, 844 individuals developed ESRD, and 853 died. In multivariable regression models, compared with men, women had significantly lower risk of ESRD, 50% eGFR decline, progression to CKD stage 5, and death. The mean unadjusted eGFR slope was -1.09 ml/min per 1.73 m² per year in women and -1.43 ml/min per 1.73 m² per year in men, but this difference was not significant after multivariable adjustment.

CONCLUSIONS

In this CKD cohort, women had lower risk of CKD progression and death compared with men. Additional investigation is needed to identify biologic and psychosocial factors underlying these sex-related differences.

Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study

BACKGROUND

Conservative care is argued to be a reasonable treatment alternative for dialysis in older patients with advanced chronic kidney disease (CKD). However, comparisons are scarce and generally focus on survival only. Comparative data on more patient-relevant outcomes are needed to truly foster shared decision-making on an individual level, and cost comparison is needed to assess value of care.

METHODS

We conducted a retrospective observational single-center cohort study in 366 patients aged ≥70 years with advanced CKD, who chose dialysis (n = 240) or conservative care (n = 126) after careful counselling by a multidisciplinary team in a non-academic teaching hospital in The Netherlands. Using a value-based health care approach (value = outcomes/cost): survival, health-related quality of life-cross-sectionally assessed with the Kidney Disease Quality of Life Short Form™-treatment burden, and treatment costs were evaluated.

RESULTS

The overall survival benefit of patients on a dialysis pathway compared with patients on conservative care diminished or lost significance in patients aged ≥80 years or with severe comorbidity. There were no differences between patients managed conservatively and dialysis patients on physical and mental health summary scores (all P > 0.1). Patients on conservative care had 352.7 hospital free days per year versus 282.7 in patients on a dialysis pathway, calculated from treatment decision (adjusted incidence rate ratio: 1.15, 95% confidence interval: 1.09 to 1.21, P <  0.001). Annual treatment costs were lower in patients on conservative care (adjusted cost ratio: 0.43, 95% confidence interval: 0.28 to 0.67, P <  0.001).

CONCLUSIONS

In this study, conservative care is shown to be a viable treatment option in older patients with advanced CKD, particularly in the oldest old and those with severe comorbidity. By achieving similar outcomes at lower treatment burden and treatment costs, value was generated for older patients choosing conservative care and society.

Discussing Conservative Management With Older Patients With CKD: An Interview Study of Nephrologists

BACKGROUND

Although dialysis may not provide a large survival benefit for older patients with kidney failure, few are informed about conservative management. Barriers and facilitators to discussions about conservative management and nephrologists' decisions to present the option of conservative management may vary within the nephrology provider community.

STUDY DESIGN

Interview study of nephrologists.

SETTING & PARTICIPANTS

National sample of US nephrologists sampled based on sex, years in practice, practice type, and region.

METHODOLOGY

Qualitative semistructured interviews continued until thematic saturation.

ANALYTICAL APPROACH

Thematic and narrative analysis of recorded and transcribed interviews.

RESULTS

Among 35 semistructured interviews with nephrologists from 18 practices, 37% described routinely discussing conservative management ("early adopters"). 5 themes and related subthemes reflected issues that influence nephrologists' decisions to discuss conservative management and their approaches to these discussions: struggling to define nephrologists' roles (determining treatment, instilling hope, and improving patient symptoms), circumventing end-of-life conversations (contending with prognostic uncertainty, fearing emotional backlash, jeopardizing relationships, and tailoring information), confronting institutional barriers (time constraints, care coordination, incentives for dialysis, and discomfort with varied conservative management approaches), conservative management as "no care," and moral distress. Nephrologists' approaches to conservative management discussions were shaped by perceptions of their roles and by a common view of conservative management as no care. Their willingness to pursue conservative management was influenced by provider- and institutional-level barriers and experiences with older patients who regretted or had been harmed by dialysis (moral distress). Early adopters routinely discussed conservative management as a way of relieving moral distress, whereas others who were more selective in discussing conservative management experienced greater distress.

LIMITATIONS

Participants' views are likely most transferable to large academic medical centers, due to oversampling of academic clinicians.

CONCLUSIONS

Our findings clarify how moral distress serves as a catalyst for conservative management discussion and highlight points of intervention and mechanisms potentially underlying low conservative management use in the United States.

Conservative care as a treatment option for patients aged 75 years and older with CKD stage V: a National survey in the Netherlands

Background and objectives

Conservative care for patients aged 75 years and older with CKD stage 5 as a treatment option besides dialysis was proposed officially in the Netherlands in October 2016. This national survey showed the current implementation of this option in Netherlands nephrology departments.

Design, setting, participants and measurement

A web-based survey was sent to medical managers of 60 nephrology departments in the Netherlands in August 2016.

Results

Twenty-one medical managers (35%) completed the survey. The term “conservative care” is frequently used and well known. The estimated number of patients in whom the decision for maximal conservative care was made in 2015 was 310 of 2249 patients with CKD stage 5 age 75 years and older (range 5–50 patients per department). 164 patients became symptomatic and received no dialysis. There is no official registration for this treatment option and patient category. The practice patterns vary widely. Only one of 21 respondents reported a conservative care outpatient clinic. Formal training or education regarding conservative care is not available in most of departments. 95% of respondents discussed this treatment option with their patients. General practitioners are always being informed about their patient’s decision. Their main role is providing or organizing palliative care support at the end of life and discussing advance care planning. Most respondents (86%) considered to include their patients in a prospective multicentre observational study, conservative care versus dialysis.

Conclusions

Conservative care as a treatment option for patients with CKD stage 5 aged 75 years and older is well established. The practice patterns are varied in the Netherlands. Follow-up studies are needed to see whether the new multidisciplinary guideline facilitates harmonization of practice pattern. Funding is needed to optimize the implementation of conservative care.

Supportive palliative care should be integrated into routine care for paediatric patients with life-limiting kidney disease

Paediatric palliative care is no longer restricted to patients with cancer and has been extended to patients with other chronic conditions, such as cystic fibrosis or neuromuscular disorders. This review focused on the current state of palliative care for children and adolescents with chronic kidney disease (CKD). We assessed the literature on CKD published up to August 2017. All the papers, except one from 1996, were published this century. This review discusses the role that palliative care plays in the process of decision-making and explores the possibilities of implementing palliative care into the routine therapy of affected patients and providing support for their families. Offering early palliative care as an integral part of the kidney, supportive care provided by the nephrology care team is both necessary and feasible for patients with CKD. As a minimum, a specialised palliative care team should be involved in patients with multiple comorbidities, in conservative treatment scenarios and in acute life-threatening complications. Further studies and guidelines are required to improve the care of patients with CKD and their families.

CONCLUSION

Supportive palliative care should be implemented into the routine care of patients with life-limiting kidney disease.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Survival analysis of conservative vs. dialysis treatment of elderly patients with CKD stage 5

Elderly patients represent a growing population among people suffering from ESRD. So far only limited data on actual survival benefits of elderly adults initiating dialysis have been published. Besides the high burden of preexisting comorbidities, dialysis treatment itself may be associated with a further deterioration in functional status in this population. We retrospectively analyzed the Austrian Dialysis and Transplant Registry and identified 8,622 patients who started maintenance hemodialysis after the age of 65 years between 2002 and 2009. We compared this data set to a cohort of 174 patients aged over 65 years with CKD stage 5 who progressed to an eGFR < 10ml/min/ and were managed conservatively in the same era. All patients who died of malignant disease were excluded from this analysis. The risk of mortality was analyzed using multivariable Cox proportional hazards models. Furthermore, a parametric model of time to event analysis was used for visualization of changing risk over time and precise calculation of time to equal risk assuming a Weibull distribution. Hemodialysis treatment was associated with a decreased risk for death with a HR of 0.23 (95% CI 0.18 to 0.29; p<0.001) compared to conservative treatment. The time to event analysis however showed, that although survival was initially superior in the hemodialysis group, hazards crossed thereafter. Time to equal risk was 2.9 months and 1.9 months for female and male patient aged 65, respectively, and decreased to one month in the very elderly aged 95. Elderly patients with ERSD did benefit from initiation of hemodialysis, as the conservative group showed a very high initial mortality rate. This survival benefit of dialysis treatment however did not persist beyond the first two months compared to survivors of the conservative group.

Time-Varying Association of Individual BP Components with eGFR in Late-Stage CKD

BACKGROUND AND OBJECTIVES

The association of individual BP components with changes in eGFR in patients with late-stage CKD is unknown. The objectives of our study were to examine the associations of systolic BP, diastolic BP, and pulse pressure with continuous temporal changes in eGFR and an eGFR decline ≥30% in late-stage CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a retrospective cohort study (2010-2015) of patients with CKD in a multidisciplinary CKD clinic with an eGFR≤30. The associations of repeat measures of BP (systolic BP, diastolic BP, and pulse pressure) with eGFR were examined using general linear mixed models. The associations of BP components and eGFR decline ≥30% were examined with time-varying Cox models.

RESULTS

In total, 1203 patients were followed for a median of 548 days (interquartile range, 292-913), with an average of 6.7 visits and BP measures per patient. Mean baseline systolic BP, diastolic BP, pulse pressure, and eGFR were 139.2 mmHg, 73.2 mmHg, 64.9 mmHg, and 16.8 ml/min, respectively. Systolic BP and diastolic BP measures over time were statistically significantly associated with changes in eGFR (P<0.001), whereas pulse pressure was not. Patients with extremes of systolic BP (<105 or >170) and high diastolic BP (>90) measures were at a higher risk of GFR decline ≥30% (systolic BP <105: hazard ratio, 1.51; 95% confidence interval, 0.98 to 2.34; systolic BP >170: hazard ratio, 1.62; 95% confidence interval, 1.05 to 2.49; referent systolic BP =121-130; diastolic BP =81-90: hazard ratio, 1.40; 95% confidence interval, 0.99 to 1.86; diastolic BP >90: hazard ratio, 1.83; 95% confidence interval, 1.21 to 2.77; referent diastolic BP =61-70). The findings were consistent after multiple sensitivity analyses. Pulse pressure was not significantly associated with risk of eGFR decline.

CONCLUSIONS

In patients referred to a multidisciplinary care clinic with late-stage CKD, only extremes of systolic BP and elevations of diastolic BP were associated with eGFR decline.

Older patient considering treatment for advanced renal disease: protocol for a scoping review of the information available for shared decision-making

INTRODUCTION

Older adults constitute the largest group of patients on dialysis in most parts of the world. Management of advanced renal disease in the older adult is complex; treatment outcomes and prognosis can be markedly different from younger patients. Clinical teams caring for such patients are often called on to provide information regarding prognosis and outcomes with treatment-particularly, the comparison between having dialysis treatment versus not having dialysis. These discussions can be difficult for clinicians because they have to contend with incomplete or nascent data regarding prognosis and outcomes in this age group. We aim to summarise the currently available information regarding the prognosis and outcomes of advanced renal disease in the older adult by means of a scoping review of the literature. This article discusses our protocol.

METHODS

This scoping review will be undertaken in accordance with the Joanna Briggs Institute's methodology for scoping reviews. A directed search will look for relevant articles in English (within electronic databases and the grey literature), written between 2000 and 2016, which have studied older patients with advanced renal disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). After screening by two independent reviewers, selected articles will be analysed using a data charting tool. Reporting will include descriptions, analysis of themes using qualitative software and display of information using charts.

ETHICS AND DISSEMINATION

This scoping review will analyse previously collected data, and so does not require ethical approval. Results will be disseminated through academic journals, conferences and seminars. We anticipate that our summary of the currently available knowledge regarding the older adult with advanced renal disease will be a repository of information for clinicians in the field. We expect to identify areas of study that are suited to systematic reviews. Our findings can also be expected to influence guidelines and clinical practice recommendations in the future.

Peritoneal dialysis: An effective yet underused renal replacement therapy

Chronic kidney disease affects more than 30 million people in the United States, creating a significant disease burden. Peritoneal dialysis, an effective yet underused method of renal replacement therapy, can provide a high quality of life, maintain a patient's residual renal function, and decrease overall healthcare costs with little negative effect on patient morbidity or mortality. Given this, knowledge of the methods, outcomes, and costs of renal replacement therapy is essential to physician assistants.

Conservative care of the patient with end-stage renal disease

'Conservative care' is the management of end-stage kidney disease without dialysis, ie a palliative approach. It is now well established as the fourth treatment option alongside haemodialysis, peritoneal dialysis and transplantation, in the majority of UK renal centres.

A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Background

Conservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.

Aim

To determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.

Objectives

(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.

Methods

Mixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.

Results

Sixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.

Conclusions

Conservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient-centered care: an opportunity to accomplish the "Three Aims" of the National Quality Strategy in the Medicare ESRD program

In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients.

Conservative care for ESRD in the United Kingdom: a national survey

BACKGROUND AND OBJECTIVES

Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.

RESULTS

Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥ 75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5-22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.

CONCLUSIONS

CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

The impact of dialysis therapy on older patients with advanced chronic kidney disease: a nationwide population-based study

BACKGROUND

Older patients with advanced chronic kidney disease (CKD) face the decision of whether to undergo dialysis. Currently available data on this issue are limited because they were generated by small, short-term studies with statistical drawbacks. Further research is urgently needed to provide objective information for dialysis decision making in older patients with advanced CKD.

METHODS

This nationwide population-based cohort study was conducted using Taiwan's National Health Insurance Research Database. Data from 2000 to 2010 were extracted. A total of 8,341 patients≥70 years old with advanced CKD and serum creatinine levels>6 mg/dl, who had been treated with erythropoiesis-stimulating agents were included. Cox proportional hazard models in which initiation of chronic dialysis was defined as the time-dependent covariate were used to calculate adjusted hazard ratios for mortality. The endpoint was all-cause mortality.

RESULTS

During a median follow-up period of 2.7 years, 6,292 (75.4%) older patients chose dialysis therapy and 2,049 (24.6%) received conservative care. Dialysis was initiated to treat kidney failure a median of 6.4 months after enrollment. Dialysis was associated with a 1.4-fold increased risk of mortality compared with conservative care (adjusted hazard ratio 1.39, 95% confidence interval 1.30 to 1.49). In subgroup analyses, the risk of mortality remained consistently increased, independent of age, sex and comorbidities.

CONCLUSIONS

In older patients, dialysis may be associated with increased mortality risk and healthcare cost compared with conservative care. For patients who are ≥70 years old with advanced CKD, decision making about whether to undergo dialysis should be weighted by consideration of risks and benefits.

The experiences of close persons caring for people with chronic kidney disease stage 5 on conservative kidney management: contested discourses of ageing

Chronic kidney disease stage 5 is a global health challenge in the context of population ageing across the world. The range of treatment options available to patients at all ages has increased and includes transplantation and dialysis. However, these options are often seen as inappropriate for older frailer patients who are now offered the option of conservative kidney management, which is presented as a non-invasive alternative to dialysis, involving symptom management and addressing psychosocial needs. In this study, we conducted qualitative interviews with 26 close persons caring for someone with chronic kidney disease stage 5 in the United Kingdom to investigate how conservative kidney management interacted with implicit ideas of ageing, in both the experience of conservative kidney management and the understanding of the prognosis and future care of the kidney disease. Our findings highlighted participant confusion about the nature of conservative kidney management, which stems from an initial lack of clarity about how conservative kidney management differed from conventional treatments for chronic kidney disease stage 5. In particular, some respondents were not aware of the implicit palliative nature of the intervention or indeed the inevitable end-of-life issues. Although these findings can be situated within the context of communication failure, we would further argue that they also bring to the surface tensions in the discourses surrounding ageing and old age, drawing on the use of a ‘natural’ and a ‘normal’ paradigm of ageing. In the context of chronic kidney disease stage 5, more patients are being dialysed at older ages, but conservative kidney management is being advanced as a better option than dialysis in terms of quality of life and experience. However, in doing so, conservative kidney management implicitly draws on a notion of older age that echoes natural ageing rather than advocate a more interventionist approach. The role of discourses of ageing in the provision of treatments for conservative kidney management has not previously been acknowledged, and this article addresses this gap.

Patient perspectives on informed decision-making surrounding dialysis initiation

BACKGROUND

Careful patient-clinician shared decision-making about dialysis initiation has been promoted, but few studies have addressed patient perspectives on the extent of information provided and how decisions to start dialysis are made.

METHODS

Ninety-nine maintenance dialysis patients recruited from 15 outpatient dialysis centers in North Carolina completed semistructured interviews on information provision and communication about the initiation of dialysis. These data were examined with content analysis. In addition, informed decision-making (IDM) scores were created by summing patient responses (yes/no) to 10 questions about the decision-making.

RESULTS

The mean IDM score was 4.4 (of 10; SD = 2.0); 67% scored 5 or lower. Age at the time of decision-making (r = -0.27, P = 0.006), years of education (r = 0.24, P = 0.02) and presence of a warning about progressing to end-stage kidney disease (t = 2.9, P = 0.005) were significantly associated with IDM scores. Nearly 70% said that the risks and burdens of dialysis were not mentioned at all, and only one patient recalled that the doctor offered the option of not starting dialysis. While a majority (67%) said that they felt they had no choice about starting dialysis (because the alternative would be death) or about dialysis modality, only 21.2% said that they had felt rushed to make a decision. About one-third of the patients perceived that the decision to start dialysis and modality was already made by the doctor.

CONCLUSIONS

A majority of patients felt unprepared and ill-informed about the initiation of dialysis. Improving the extent of IDM about dialysis may optimize patient preparation prior to starting treatment and their perceptions about the decision-making process.

Palliative care for advanced renal disease: a summary of the evidence and future direction

BACKGROUND

Patients with end-stage kidney disease can have a significant symptom burden with complex co-morbidities. Compounding this is the choice between dialysis and conservative management. NEED FOR SUPPORTIVE AND PALLIATIVE CARE: For individuals with end-stage kidney disease, palliative care can provide support with symptom management, advance care planning and psychological support and education for both patients and their families. Optimum management may be achieved through collaboration between renal and palliative care professionals, combining their different skills in addressing symptom and medication management. Palliative and supportive care must be patient-centred to be effective. Multidisciplinary cross-organisational input is central to address the complex care needs of these patients, particularly for those in the community. WHAT IS KNOWN/WHAT IS NOT KNOWN: There is growing awareness of the need for research into the palliative care needs of those with end-stage kidney disease. Research has shown that patients receiving dialysis may prioritise quality of life over survival time, partly due to the constraints that they feel dialysis imposes on them. Systematic study of those opting for a conservative management pathway rather than dialysis is beginning to happen.

RESEARCH IMPLICATIONS

Research is required into what underpins the preferences and priorities of patients with end-stage kidney disease to provide them with the best palliative and supportive care. POLICY AND PRACTICE: As more patients opt to follow the conservative pathway for their advanced renal disease, a change in service provision is required, with greater regular inclusion of palliative and supportive needs to address the gap in the care provision for this growing group.

Dialysis initiation: what's the rush?

The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided.