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

Abstract

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.

Keywords: dialysis; elderly patients; palliative care; renal supportive care.

Figure 1.

Pathways of the 467 patients, showing the course of those who commenced in the predialysis clinic (n=273), those in the RSC-NFD group clinic (n=122), and the “other dialysis” group (n=72). RSC-NFD, renal supportive care not planned for dialysis.

Figure 2.

Survival in patients in the predialysis (n=273) or RSC-NFD (n=122) groups. Time zero is from first attendance at the predialysis or renal supportive care clinic after a decision had been made to pursue dialysis or not.

Figure 3.

Survival in patients who remained in the predialysis clinic without receiving dialysis (n=181) compared with all of those receiving dialysis in this period (n=164) and patients in the RSC-NFD group (n=122). Time zero is from first attendance at the predialysis or renal supportive care clinic after a decision had been made to pursue dialysis or not. For the “all dialysis” group, this time point includes the time at first dialysis for the 72 patients who had not attended the predialysis clinic.