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Opting out of dialysis not an immediate death sentence in advanced kidney disease

JAMA Network Open
Reuters Health - 14/03/2022 - Many older patients with advanced chronic kidney disease (CKD) who forgo dialysis survive several years with good quality of life until late in their illness course, new research suggests.

"Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced CKD is no care or death," Dr. Susan Wong of the University of Washington, in Seattle, and colleagues write in JAMA Network Open.

The findings are based on a systematic review including 41 cohort studies comprising 5,102 older adults with advanced CKD who did not pursue maintenance dialysis.

Median survival ranged from one to 41 months, corresponding to a wide range of baseline mean estimated glomerular filtration rate (range, 7 to 19 mL/min/1.73 m2).

"Despite the advanced ages and significant comorbid burden of cohorts in this study, most patients survived several years after the decision to forgo dialysis was made," the researchers report. "We also found that mental well-being improved over time and that physical well-being and overall quality of life were largely stable until late in the illness course."

Overall, the findings suggest that conservative kidney management may be a "viable and positive therapeutic alternative to dialysis," they say.

The findings also underscore the need to develop models of care that optimize outcomes for those who decide not to pursue dialysis, "who have the potential to live well and for quite some time without dialysis," Dr. Wong and colleagues suggest.

The authors of an invited commentary say this work "dispels the notion that conservative care for kidney failure means a grim and near-immediate death."

"Considered against available data on the survival and quality of life provided by dialysis, the study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients' life goals," write Drs. Christine Liu and Manjula Kurella Tamura with Stanford University in California.

They say the study also raises a larger question. "If professional societies have endorsed shared decision making for kidney failure and recognize that conservative kidney care can be appropriate patient-centered treatment, why do we lack information systems to monitor the outcomes of conservative care?"

"It seems fundamental that quality, safety, and costs of kidney failure therapy cannot be fully understood by examining only one side of the coin. We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure," they say.

The study by Dr. Wong and colleagues is "a reminder that to optimally support shared decision-making and the dissemination of best practices, we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision making," they conclude.

SOURCE: https://bit.ly/3IeMRfA and https://bit.ly/3JfM0ww JAMA Network Open, online March 14, 2022.

By Reuters Staff

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