Dataset Information

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.

ABSTRACT:

Background and objectives

Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.

Design, setting, participants, & measurements

A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ?70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded.

Results

In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ?80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ?70 years old with Davies comorbidity scores of ?3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02).

Conclusions

In this single-center observational study, there was no statistically significant survival advantage among patients ages ?80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.

SUBMITTER: Verberne WR

PROVIDER: S-EPMC4822664 | biostudies-literature | 2016 Apr

REPOSITORIES: biostudies-literature

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Publications

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.

Verberne Wouter R WR Geers A B M Tom AB Jellema Wilbert T WT Vincent Hieronymus H HH van Delden Johannes J M JJ Bos Willem Jan W WJ

Clinical journal of the American Society of Nephrology : CJASN 20160317 4

<h4>Background and objectives</h4>Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.<h4>Design, setting, participants, & measurements</h4>A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patie ...[more]

PMID: 26988748

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Project description:BACKGROUND:Conservative care is argued to be a reasonable treatment alternative for dialysis in older patients with advanced chronic kidney disease (CKD). However, comparisons are scarce and generally focus on survival only. Comparative data on more patient-relevant outcomes are needed to truly foster shared decision-making on an individual level, and cost comparison is needed to assess value of care. METHODS:We conducted a retrospective observational single-center cohort study in 366 patients aged ?70 years with advanced CKD, who chose dialysis (n =?240) or conservative care (n =?126) after careful counselling by a multidisciplinary team in a non-academic teaching hospital in The Netherlands. Using a value-based health care approach (value?=?outcomes/cost): survival, health-related quality of life-cross-sectionally assessed with the Kidney Disease Quality of Life Short Form™-treatment burden, and treatment costs were evaluated. RESULTS:The overall survival benefit of patients on a dialysis pathway compared with patients on conservative care diminished or lost significance in patients aged ?80 years or with severe comorbidity. There were no differences between patients managed conservatively and dialysis patients on physical and mental health summary scores (all P >?0.1). Patients on conservative care had 352.7 hospital free days per year versus 282.7 in patients on a dialysis pathway, calculated from treatment decision (adjusted incidence rate ratio: 1.15, 95% confidence interval: 1.09 to 1.21, P <? 0.001). Annual treatment costs were lower in patients on conservative care (adjusted cost ratio: 0.43, 95% confidence interval: 0.28 to 0.67, P <? 0.001). CONCLUSIONS:In this study, conservative care is shown to be a viable treatment option in older patients with advanced CKD, particularly in the oldest old and those with severe comorbidity. By achieving similar outcomes at lower treatment burden and treatment costs, value was generated for older patients choosing conservative care and society.

Project description:Rationale & objectiveOlder patients with advanced chronic kidney disease (CKD) use intensive care at the end of life and die in a hospital more frequently than patients with cancer or heart disease. Advance care planning (ACP) can help align treatment with patient preferences and improve patient-centered care, yet ACP quality and experiences among older patients with CKD and their care partners remain incompletely understood, particularly among the non-dialysis-dependent population.Study designIn-person interviewer-administered surveys of patients 70 years and older with non-dialysis-dependent CKD stage 4 or 5 and their self-identified care partners.Setting & participants42 participants (31 patients, 11 care partners) at 2 clinical sites in greater Boston.OutcomesCompletion of advance directives and self-reported perceptions, preferences, and experiences of ACP.Analytical approachDescriptive analysis of patient and care partner surveys. McNemar test analysis to compare patient and care partner responses.ResultsMost patients had written advance directives (64%) and surrogate decision makers (81%). Although patients reported positive perceptions and high trust in their clinicians' judgment, few (16%) had actually discussed preferences for life-sustaining treatment with their nephrologists. Few ACP discussions included components reflective of high-quality ACP: 16% of patients had been asked about their values concerning end-of-life care and 7% had discussed issues of decision-making capacity and consent to care should their health decline. When presented with 2 hypothetical scenarios (stroke/heart attack or dementia), nearly all patients and care partners reported a preference for comfort care over delaying death. Care partners were more likely than patients to report that they had experienced discussion components reflective of high-quality ACP with the clinical team.LimitationsSingle metropolitan area; most patients did not identify a care partner; nonresponse bias and small sample size.ConclusionsPatients often believed that their clinicians understood their end-of-life wishes despite not having engaged in ACP conversations that would make those wishes known. Improving clinical ACP communication may result in end-of-life treatment that better aligns with patient goals.

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Dataset Information

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.

Background and objectives

Design, setting, participants, & measurements

Results

Conclusions

Publications

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.

Similar Datasets

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