Dialysis Therapy and Conservative Management of Advanced Chronic Kidney Disease in the Elderly: A Systematic Review

Abstract

Background: Dialysis in older adults with chronic kidney disease (CKD) and comorbidities may not be associated with improved life expectancy compared to conservative management. To inform clinical practice, we performed a systematic review of all available studies examining this hypothesis. Methods: We performed a systematic review of retrospective and prospective cohort studies of older adults with stage-5 CKD who chose dialysis (hemodialysis or peritoneal dialysis) or opted for conservative management (including management of complications of CKD and palliative care). Outcomes of interest included hospitalizations and mortality. Results: Twelve cohort studies (11,515 patients) were identified with most of them focusing on older adults. Patients choosing dialysis were younger compared to those opting for conservative management and were less functionally impaired. Patients opting for conservative management received care in a multidisciplinary setting focusing on palliative care and management of complications of CKD. Patients choosing dialysis and conservative management had a median survival time of 8-67 and 6-30 months, respectively. In a subset of studies of patients 65 years and older with an estimated glomerular filtration rate <15 mL/min/1.73 m², and where the multivariable analyses included age and comorbidities, by meta-analysis, patients choosing dialysis had a pooled adjusted hazard ratio for mortality of 0.53 (95% CI 0.30-0.91, p = 0.02) relative to those opting for conservative management; however, significant heterogeneity precluded definitive conclusions. Conclusions: When caring for older adults with advanced CKD who are contemplating dialysis therapy vs. conservative management, efforts must focus on promoting patient values and preferences, shared decision-making, and symptom burden alleviation.

Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status

“…Prescription of all treatments, including dialysis, should first of all comply with the imperative “do no harm” [ 24 , 25 , 26 ]. The high mortality on initiation of dialysis, recently termed “dialysis shock” and the lack of advantages (and possible disadvantages) of early versus late dialysis initiation, together with the contrasting results of dialysis or supportive treatment in the elderly, indicate that dialysis saves lives, but not without cost [ 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

Making Sense of Prognostic Information About Maintenance Dialysis versus Conservative Care for Treatment of Advanced Kidney Disease

“…Decisions about whether to pursue dialysis under such circumstances seem quite distinct from those made earlier in the illness trajectory of the sort described in the studies reviewed by Wongrakpanich et al [ 16 ] , where survival can sometimes be quite similar for patients who choose conservative care vs. dialysis. Thus, upholding patients' wishes not to pursue dialysis in the United States will likely require cultural and infrastructural commitment to building conservative care programs for advanced CKD resembling those emerging in other countries.…”

“…In this issue, Wongrakpanich et al [16 ] describe their work to conduct a systematic review and meta-analysis of cohort studies that compared the clinical course of patients with advanced CKD who opted for conservative management vs. maintenance dialysis. A total of 12 cohort studies (11,515 patients) published between 2003 and 2016 were included in the review.…”

Shared decision-making in advanced kidney disease: a scoping review protocol

“…When it comes to treatment modality decision-making in AKD, no papers present a thorough overview of existing SDM interventions with evidence on any of their outcomes or novel developments in this field. Systematic reviews, including meta-analyses, have been written on: the perspectives of living with kidney failure19; factors influencing the decision-making process regarding treatment modalities for patients with AKD20–25; the readability of written materials for patients with chronic kidney disease (CKD)26 27; the effects of education and cognition of patients on SDM28–30; the validity of prognostic algorithms for this decision-making process31; advanced care planning32 33 and treatment outcomes in the elderly 34–38. Furthermore, a preliminary search in the PubMed, Medline, Embase, Web of Science, Cochrane Library, Emcare, International Prospective Register of Systematic Reviews (PROSPERO), PsycINFO and Academic Search Premier databases did not identify any scoping reviews on this subject.…”