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Kidney Week

Abstract: TH-PO646

Survival of Elderly Patients with ESKD Managed Without Dialysis

Session Information

  • Geriatric Nephrology
    November 07, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Chou, Angela, St George Hospital, Cabramatta, New South Wales, Australia
  • Li, Kelly Chenlei, St George Hospital, NSW, Australia, Kogarah NSW, New South Wales, Australia
  • Hoffman, Anna, St George Hospital Sydney, Kogarah, New South Wales, Australia
  • Brown, Mark, St. George Hospital, Sydney, New South Wales, Australia
Background

Shared decision making (SDM) is important when considering whether an elderly patient ESKD should be managed with dialysis. Research has shown that physicians find these conversations difficult because of the relative paucity of data on survival of patients managed without dialysis.

Methods

We conducted a prospective observational study of 580 patients with CKD stages 4-5, aged ≤ 65 years between March 2009-August 2018 in our renal unit where SDM is actively implemented and conservative management is supported by a specific Renal Supportive Care (RSC) program. 148 dialysis patients attended the Pre-dialysis education clinic (PEC), 82 had not (non-PEC), and 280 patients were managed conservatively (CM) with RSC, an embedded multidisciplinary renal palliative care clinic. Survival was evaluated from: (1) Clinical pathway decision date; (2) eGFR ≤ 15; and (3) eGFR ≤ 10. Cox models were used to estimate survival adjusted for potential confounders identified as significant after multivariate regression analysis.

Results

CM patients were significantly older than PEC and non-PEC dialysis patients (mean±SD: 84±6 vs. 74±6 vs. 76±6; p<0.01) and had greater comorbidity (<0.01). From decision date, median survival was 6.0 years (Interquartile range [IQR] 2.5-9.5) in PEC compared with 3.3 (IQR 0.7-5.0) in non-PEC dialysis and 1.1 yrs. (IQR 0.4-1.7) in CM; p <0.01. From time eGFR ≤ 15, median survival was 7.8 years (IQR 3.5-12.6) in PEC, 5.6 (IQR 0.8-6.5) in non-PEC and 1.3 (IQR 0.5-2.0) in CM; p <0.01. From eGFR ≤ 10, median survival was 6.4 years (IQR 2.4-10.4) in PEC, 2.4 (IQR 0.5-6.0) in non-PEC and 0.7 (IQR 0.2-1.4) in CM; p <0.001. Non-PEC patients had lower eGFR than PEC at time of first visit (9±4 vs. 16±5 ml/min/1.73m2, p<0.01). In the CM group, at least 51 (18%) patients did not reach eGFR ≤ 15 and the cause of death was mainly non-renal (41 out of 51; 92%). Older age reduced survival from decision date (HR 1.03, 95% CI 1.01-1.049; p<0.01).

Conclusion

The median survival of elderly patients managed conservatively was 15.4 and 8.5 months from the time of eGFR ≤ 15 and ≤ 10 respectively. Elderly patients who did not attend dialysis education prior to initiation had worse survival. This data should assist physicians with SDM discussions.