Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?

Rachel C Carson, Maciej Juszczak, Andrew Davenport, Aine Burns, Rachel C Carson, Maciej Juszczak, Andrew Davenport, Aine Burns

Abstract

Background and objectives: There is ongoing growth of elderly populations with ESRD in Western Europe and North America. In our center, we offer an alternative care pathway of 'maximum conservative management' (MCM) to patients who elect not to start dialysis, often because of a heavy burden of comorbid illness and advanced age. The objective of our study was to compare clinical outcomes for patients who had ESRD and chose either MCM or renal replacement therapy (RRT).

Design, setting, participants, & measurements: This is an observational study of a single-center cohort in the United Kingdom that evaluating 202 elderly (> or =70 yr) patients who had ESRD and had chosen either MCM (n = 29) or RRT (n = 173). We report survival, hospitalization rates, and location of death for this cohort. Survival was measured from a standardized 'threshold' estimated GFR of 10.8 ml/min per 1.73 m(2).

Results: Median survival, including the first 90 d, was 37.8 mo (range 0 to 106 mo) for RRT patients and 13.9 mo (range 2 to 44) for MCM patients (P < 0.01). RRT patients had higher rates of hospitalization (0.069 [95% confidence interval (CI) 0.068 to 0.070]) versus 0.043 [95% CI 0.040 to 0.047] hospital days/patient-days survived) compared with MCM patients. MCM patients were significantly more likely to die at home or in a hospice (odds ratio 4.15; 95% CI 1.67 to 10.25). A survey of the literature describing elderly ESRD outcomes is also presented.

Conclusions: Dialysis prolongs survival for elderly patients who have ESRD with significant comorbidity by approximately 2 yr; however, patients who choose MCM can survive a substantial length of time, achieving similar numbers of hospital-free days to patients who choose hemodialysis.

Figures

Figure 1.
Figure 1.
Flowsheet of all incident dialysis patients who were aged ≥70 yr and patients who opted for MCM, showing outcomes, exclusions and patients who were lost to follow-up.
Figure 2.
Figure 2.
Kaplan-Meier survival curves. (A) MCM versus all RRT (from day 0). (B) MCM versus all RRT (from day 90). (C) MCM versus RRT emergency referral subgroup versus RRT nonemergency referral subgroup (from day 0).
Figure 3.
Figure 3.
Median survival for MCM cohort and the hemodialysis-only subgroup in the RRT cohort. Data shown are how many days were spent hospital-free, compared with in-patient stays in hospital and outpatient hospital attendances for dialysis.
Figure 4.
Figure 4.
Literature survey: Summary graph of survival of elderly patients with ESRD in previous studies.

References

    1. Farrington K, Rao R, Gilg J, Ansell D, Feest T: Chapter 3: New adult patients starting renal replacement therapy in the UK in 2005. In: UK Renal Registry: The Ninth Annual Report, edited by Ansell D, Feest T, Hodsman A, Rao R, Tomson C, Udayaraj U, Williams A, Warwick G.Bristol, United Kingdom, The Renal Association, 2006, pp 15– 41
    1. Kurella M, Covinsky KE, Collins AJ, Chertow GM: Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 146: 177– 183, 2007
    1. Collins AJ, Foley R, Herzog C, Chavers B, Gilbertson D, Ishani A, Kasiske B, Liu J, Mau LW, Mcbean M, Murray A, St. Peter W, Xue J, Fan Q, Guo H, Li Q, Li S, Peng Y, Qiu Y, Roberts T, Skeans M, Snyder J, Solid C, Wang C, Weinhandl E, Zaun D, Zhang R, Arko C, Chen SC, Dalleska F, Daniels F, Dunning S, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L: Excerpts from the United States Renal Data System 2007 annual data report: ESRD incidence and prevalence. Am J Kidney Dis 51: S81– S98, 2008
    1. Collins AJ, Foley R, Herzog C, Chavers B, Gilbertson D, Ishani A, Kasiske B, Liu J, Mau LW, Mcbean M, Murray A, St. Peter W, Xue J, Fan Q, Guo H, Li Q, Li S, Peng Y, Qiu Y, Roberts T, Skeans M, Snyder J, Solid C, Wang C, Weinhandl E, Zaun D, Zhang R, Arko C, Chen SC, Dalleska F, Daniels F, Dunning S, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L: Excerpts from the United States Renal Data System 2007 annual data report: Emerging issues. Am J Kidney Dis 51: S33– S48, 2008
    1. Krishnan M, Lok CE, Jassal SV: Epidemiology and demographic aspects of treated end-stage renal disease in the elderly. Semin Dial 15: 79– 83, 2002
    1. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE: Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 22: 1955– 1962, 2007
    1. Mallick N, El Marasi A: Dialysis in the elderly: To treat or not to treat? Nephrol Dial Transplant 14: 37– 39, 1999
    1. Smith C, Da Silva-Gane M, Chandna S, Warwicker P, Greenwood R, Farrington K: Choosing not to dialyse: Evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure. Nephron Clin Pract 95: c40– c46, 2003
    1. Wong CF, Mccarthy M, Howse ML, Williams PS: Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis. Ren Fail 29: 653– 659, 2007
    1. Chapter 15: Elderly patients on renal replacement therapy. In: UK Renal Registry: The Seventh Annual Report, edited by Ansell D, Feest T, Ahmad A, Rao R.Bristol, United Kingdom, The Renal Association, 2004, pp 227– 239
    1. Joly D, Anglicheau D, Alberti C, Nguyen AT, Touam M, Grunfeld JP, Jungers P: Octogenarians reaching end-stage renal disease: Cohort study of decision-making and clinical outcomes. J Am Soc Nephrol 14: 1012– 1021, 2003
    1. Williams B, Mcdaid R, Walker R, Quarterly R, Cross J, Burns A: Maximum Conservative Management of End Stage Renal Failure. What Can Patients and Their Families Expect? Renal Association Autumn 2002 Meeting.Royal College of Physicians, London, Renal Association, 2002, pp 52
    1. Levey AS, Greene T, Kusek JW, Beck GJ: A simplified equation to predict glomerular filtration rate from serum creatinine [Abstract]. J Am Soc Nephrol 11: A0828, 2000
    1. Hemmelgarn BR, Manns BJ, Quan H, Ghali WA: Adapting the Charlson Comorbidity Index for use in patients with ESRD. Am J Kidney Dis 42: 125– 132, 2003
    1. Hall WH, Ramachandran R, Narayan S, Jani AB, Vijayakumar S: An electronic application for rapidly calculating Charlson comorbidity score. BMC Cancer 4: 94, 2004
    1. Hirsch DJ, West ML, Cohen AD, Jindal KK: Experience with not offering dialysis to patients with a poor prognosis. Am J Kidney Dis 23: 463– 466, 1994
    1. Mendelssohn DC, Kua BT, Singer PA: Referral for dialysis in Ontario. Arch Intern Med 155: 2473– 2478, 1995
    1. Sekkarie M, Cosma M, Mendelssohn D: Nonreferral and nonacceptance to dialysis by primary care physicians and nephrologists in Canada and the United States. Am J Kidney Dis 38: 36– 41, 2001
    1. Cohen LM, Germain M, Poppel DM, Woods A, Kjellstrand CM: Dialysis discontinuation and palliative care. Am J Kidney Dis 36: 140– 144, 2000
    1. Rohrich B, Von Herrath D, Asmus G, Schaefer K: The elderly dialysis patient: Management of the hospital stay. Nephrol Dial Transplant 13[ Suppl 7]: 69– 72, 1998
    1. Issad B, Benevent D, Allouache M, Durand PY, Aguilera D, Milongo R, Dubot P, Lavaud S, Gary J: 213 elderly uremic patients over 75 years of age treated with long-term peritoneal dialysis: A French multicenter study. Perit Dial Int 16[ Suppl 1]: S414– S418, 1996
    1. Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson L, Harris S, Brown E, Gruen R, Victor C: Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: A prospective cohort study. Lancet 356: 1543– 1550, 2000
    1. Burrowes JD, Larive B, Cockram DB, Dwyer J, Kusek JW, Mcleroy S, Poole D, Rocco MV: Effects of dietary intake, appetite, and eating habits on dialysis and non-dialysis treatment days in hemodialysis patients: Cross-sectional results from the HEMO study. J Ren Nutr 13: 191– 198, 2003
    1. O'Hare AM, Choi AI, Bertenthal D, Bacchetti P, Garg AX, Kaufman JS, Walter LC, Mehta KM, Steinman MA, Allon M, Mcclellan WM, Landefeld CS: Age affects outcomes in chronic kidney disease. J Am Soc Nephrol 18: 2758– 2765, 2007
    1. Almond A, Siddiqui S, Robertson S, Norrie J, Isles C: Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low. QJM 101: 619– 624, 2008
    1. Cohen LM, Germain MJ, Poppel DM: Practical considerations in dialysis withdrawal: ‘To have that option is a blessing.’ JAMA 289: 2113– 2119, 2003
    1. Cohen LM, Mccue JD, Germain M, Kjellstrand CM: Dialysis discontinuation: A ‘good’ death? Arch Intern Med 155: 42– 47, 1995
    1. Holley JL: Advance care planning in elderly chronic dialysis patients. Int Urol Nephrol 35: 565– 568, 2003
    1. Holley JL, Foulks CJ, Moss AH: Nephrologists' reported attitudes about factors influencing recommendations to initiate or withdraw dialysis. J Am Soc Nephrol 1: 1284– 1288, 1991
    1. Holley JL, Hines SC, Glover JJ, Babrow AS, Badzek LA, Moss AH: Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis. Am J Kidney Dis 33: 688– 693, 1999
    1. Moss AH: Dialysis decisions and the elderly. Clin Geriatr Med 10: 463– 473, 1994
    1. Moss AH: Shared decision making in dialysis: A new clinical practice guideline to assist with dialysis-related ethics consultations. J Clin Ethics 12: 406– 414, 2001
    1. Moss AH, Holley JL, Davison SN, Dart RA, Germain MJ, Cohen L, Swartz RD: Palliative care. Am J Kidney Dis 43: 172– 173, 2004
    1. Moss AH, Stocking CB, Sachs GA, Siegler M: Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis. J Am Soc Nephrol 4: 229– 234, 1993
    1. Murtagh FE, Addington-Hall JM, Donohoe P, Higginson IJ: Symptom management in patients with established renal failure managed without dialysis. EDTNA ERCA J 32: 93– 98, 2006
    1. Singer PA: Nephrologists' experience with and attitudes towards decisions to forego dialysis. The End-Stage Renal Disease Network of New England. J Am Soc Nephrol 2: 1235– 1240, 1992
    1. Singer PA, Thiel EC, Naylor CD, Richardson RM, Llewellyn-Thomas H, Goldstein M, Saiphoo C, Uldall PR, Kim D, Mendelssohn DC: Life-sustaining treatment preferences of hemodialysis patients: Implications for advance directives. J Am Soc Nephrol 6: 1410– 1417, 1995
    1. Holley JL: Advance directives and advance care planning in patients with end-stage renal disease. In: Supportive Care for the Renal Patient, edited by Chambers EJ, Germain M, Brown E.Oxford, Oxford University Press, 2004, pp 35– 44
    1. Germain MJ, Cohen L: Supportive care for patients with renal disease: Time for action. Am J Kidney Dis 38: 884– 886, 2001
    1. Germain MJ, Cohen LM, Davison SN: Withholding and withdrawal from dialysis: What we know about how our patients die. Semin Dial 20: 195– 199, 2007
    1. Challah S, Wing AJ, Bauer R, Morris RW, Schroeder SA: Negative selection of patients for dialysis and transplantation in the United Kingdom. BMJ (Clin Res Ed) 288: 1119– 1122, 1984
    1. Kee F, Patterson CC, Wilson EA, Mcconnell JM, Wheeler SM, Watson JD: Stewardship or clinical freedom? Variations in dialysis decision making. Nephrol Dial Transplant 15: 1647– 1657, 2000

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する