Conservative managementand end of life care in australia, three year followup of a national incident cohort with end stage kidney disease

Abstract

Introduction and Aims: Up to 20% of chronic kidney disease (CKD) stage 5 patients opt for non-dialytic conservative care. However it is unclear what proportion of these patients start dialysis as their disease progresses; or whether specialist palliative care is provided. We aimed to determine the proportion of patients who commenced dialysis, or time-limited trial of dialysis, within 3 years after confirmed plans for conservative care; and to compare survival and end-of-life care for patients choosing conservative care, with those initiating renal replacement therapy (RRT). Methods: Longitudinal analysis of 721 incident dialysis, transplant and conservatively managed patients from 66 Australian renal units entered into the national Patient Information about Options for Treatment (PINOT) cohort study. Chi-square tests were used to assess differences in proportions for conservative care versus RRT groups. Cox proportional hazards models, stratified for clustering by centre and adjusted for; socio-demographic characteristics, late referral to a nephrologist, baseline serum albumin, and haemoglobin, were used to estimate factors associated with 3-year survival. Results: Of 102 patients who planned for conservative care, median age 80 years (IQR 75-85), just 8% (95%CI 4%-15%) commenced dialysis within 3 years, predominantly for symptom management. 23% (95%CI 15-31%) of 102 patients were alive at 3 years. Among the entire cohort of 721 patients, factors associated with all-cause mortality included: patient age ≥75 years (HR 2.42, 95%CI 1.69-3.47), low serum albumin at baseline (HR 4.78, 95%CI 2.89-7.89), and a conservative management plan compared to RRT (HR 2.47, 95%CI 1.53-4.00). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% vs 57%, p<0.001) and more likely to die in hospital (66% vs 42%, p<0.001) than home or hospice. Of those receiving palliative care, those with RRT management were more likely than the conservatively managed to receive palliative care only within the last week of life (42% vs 15%, p<0.001). Conclusions: Relatively few patients switch to dialysis after planned conservative care. Specialist palliative care services are utilised more frequently and earlier for conservatively managed patients, whereas palliative care is utilised quite late for patients on RRT. Further research is needed to understand the determinants of palliative care service provision and preferences for end-of-life care in a population with advanced CKD.<br />