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Kidney Week

Abstract: FR-PO326

Timing of Decisions About Conservative Management of Advanced CKD: Are We Adding to Patient Burden?

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

  • Chandna, Shahid M., Lister Hospital, Stevenage, United Kingdom
  • Da silva-gane, Maria, Lister Hospital (Renal Unit), Stevenage, United Kingdom
  • Farrington, Ken, Lister Renal Unit, Hitchin, United Kingdom
Background

Non-dialytic, Conservative management (CM) is an increasingly prevalent option for the management of advanced chronic kidney disease (CKD) – especially in patients of advanced age or with high comorbidity. There is an increasing trend for making the CM decision earlier in the course of CKD. Whilst this offers an advantage in avoidance of unnecessary preparations for dialysis, there is a risk of subjecting some patients, with very low likelihood of progression to ESRF, to unnecessary distress.

Methods

In this retrospective study, we examined all patients who had the CM decision made in our regional renal centre.

Results

From 1 January 2006 to 31 December 2015, 338 patients had the CM recorded in their diagnosis list. Median age was 82.1 (IQR 92) years. 79.8% of patients were judged as having moderate or high comorbidity. The median eGFR at the time of initiation of CM discussion with patients was 13.8 (IQR 5.7) ml/min/1.73 m2. 281 (83.1%) had died at the date of last follow up. 46% of patients had a median eGFR > 10 ml/min/1.73 m2 at last follow-up. Median eGFR at the time of death in CM patients was 9.1 ml/min/1.73 m2 (IQR 7.0). 42% of those who died had a last recorded eGFR > 10 ml/min/1.7 m2.. 32 patients (9.4%) developed severe acute kidney injury during follow-up and 8 of these (2.4%) received dialysis. 15 patients (4.4%) changed their decision from CM to dialysis.
The median rate of eGFR decline in the year before CM decision was 3.8 (IQR 6.5) ml/min/year in the whole group. eGFR at CM decision was inversely related to rate of eGFR decline in tertiles (tertile 1 [slowest decline] - 14.7 (IQR 6.7), tertile 2 -13.6 (IQR 5.4), tertile 3 – 12. 9 (IQR 5.3): p = 0.006). eGRF at CM decision was higher in patients with high comorbidity compared to those with low-moderate levels (14.7 [1QR 5.7] vs 13.5 [IQR 5.5]: p = 0.032)

Conclusion

Many patient on the conservative pathway die at relatively high levels of kidney function (eGFR >10 ml/min/1.73 m2), probably related to extrarenal comorbidity. Decision making seems to focus more on age, comorbidity, and absolute levels of eGFR than on eGFR trajectory. As a result of this it is possible that some patients are unnecessarily burdened with decisions relating to choices between options of renal replacement therapy.