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. 2009 Oct;4(10):1611-9.
doi: 10.2215/CJN.00510109. Epub 2009 Sep 24.

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

Rachel C Carson  1 , Maciej Juszczak, Andrew Davenport, Aine Burns
Affiliations

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

Rachel C Carson et al. Clin J Am Soc Nephrol. 2009 Oct.

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.

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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.
See this image and copyright information in PMC

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