Negative Selection of Patients for Dialysis and Transplantation in the United Kingdom

Challah, Sabri; Wing, A. J.; Bauer, Richard L.; Morris, RW; Schröder, Stephen

doi:10.1016/s0022-5347(17)50154-8

Cited by 15 publications

(21 citation statements)

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“…Inclusion of patients who have advanced ESRD and are actively undergoing MCM in national databases such as the UK Renal Registry and the US Renal Data System would greatly facilitate further research into prognosis and decision making for the increasing numbers of elderly patients who have ESRD with significant comorbid illness. Although studies have examined nephrologists' choices regarding whether to offer dialysis (17,18,41,42), future work needs to consider patient decision making. Our results show that for patients with an already limited life expectancy, the so-called medicalization of death is substantially greater with dialysis than without it.…”

Section: Discussionmentioning

confidence: 99%

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Carson

Juszczak

Davenport

et al. 2009

Clinical Journal of the American Society of Nephrology

402

388

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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 (>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.

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Section: Discussionmentioning

confidence: 99%

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Carson

Juszczak

Davenport

et al. 2009

Clinical Journal of the American Society of Nephrology

402

388

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“…The attitude toward accepting patients for dialysis has come a long way since 1984, when almost half of United Kingdom nephrologists would not have dialyzed a 50-year-old man with IHD (39). Today, the decision regarding whether to recommend dialysis to an elderly patient remains a difficult one.…”

Section: Symptom Control and Qolmentioning

confidence: 99%

CKD in Elderly Patients Managed without Dialysis

Brown

Collett

Josland

et al. 2015

Clinical Journal of the American Society of Nephrology

190

229

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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.

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“…Management of fluid balance, anemia, comorbid conditions, and intercurrent health problems; attempts to preserve residual kidney function where appropriate; and provision of appropriate end-of-life care are important aspects. Use of therapies in a rational and appropriate fashion must be distinguished from rationing (4,8). Rationing limits access to medical interventions to conserve resources, whereas a rational approach might entail foregoing a therapy likely to prove futile or detrimental in other ways to patient wellbeing.…”

Section: Introductionmentioning

confidence: 99%

Quality of Life and Survival in Patients with Advanced Kidney Failure Managed Conservatively or by Dialysis

Silva-Gane

Wellsted

Greenshields

et al. 2012

Clinical Journal of the American Society of Nephrology

186

199

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SummaryBackground and objectives Benefits of dialysis in elderly dependent patients are not clearcut. Some patients forego dialysis, opting for conservative kidney management (CKM). This study prospectively compared quality of life and survival in CKM patients and those opting for dialysis.Design, setting, participants, & measurements Quality-of-life assessments (Short-Form 36, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale) were performed every 3 months for up to 3 years in patients with advanced, progressive CKD (late stage 4 and stage 5).Results After 3 years, 80 and 44 of 170 patients had started or were planned for hemodialysis (HD) or peritoneal dialysis, respectively; 30 were undergoing CKM; and 16 remained undecided. Mean baseline estimated GFR ± SD was similar (14.0±4.0 ml/min per 1.73 m 2 ) in all groups but was slightly higher in undecided patients. CKM patients were older, more dependent, and more highly comorbid; had poorer physical health; and had higher anxiety levels than the dialysis patients. Mental health, depression, and life satisfaction scores were similar. Multilevel growth models demonstrated no serial change in quality-of-life measures except life satisfaction, which decreased significantly after dialysis initiation and remained stable in CKM. In Cox models controlling for comorbidity, Karnofsky performance scale score, age, physical health score, and propensity score, median survival from recruitment was 1317 days in HD patients (mean of 326 dialysis sessions) and 913 days in CKM patients. ConclusionsPatients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.

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Negative Selection of Patients for Dialysis and Transplantation in the United Kingdom

Cited by 15 publications

References 0 publications

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

Is Maximum Conservative Management an Equivalent Treatment Option to Dialysis for Elderly Patients with Significant Comorbid Disease?

CKD in Elderly Patients Managed without Dialysis

Quality of Life and Survival in Patients with Advanced Kidney Failure Managed Conservatively or by Dialysis

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