Perspective from Dale Lupu, MPH, PhD
Disclosures: Wong reports receiving grants from the NIH and Doris Duke Charitable Foundation outside the submitted work.

March 21, 2022
2 min read
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Patients with advanced CKD can experience improved quality of life without using dialysis

Perspective from Dale Lupu, MPH, PhD
Disclosures: Wong reports receiving grants from the NIH and Doris Duke Charitable Foundation outside the submitted work.

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Patients with advanced chronic kidney disease who choose not to use dialysis can survive many years with improvements to their mental health, in addition to stable physical health and quality of life until late into the illness, data show.

However, researchers found several patients used acute care services and there were significant disparities in access to end-of-life care. Researchers noted more research is needed to optimize outcomes among patients who are not treated with dialysis.

“Prior systematic reviews and meta-analyses reflect only a small fraction of the patients who forgo dialysis described in the literature and provide only a limited view of the clinical course of patients to guide ongoing management and anticipatory guidance to patients who have already decided that they will not pursue dialysis,” Susan P. Y. Wong, MD, MS, from the division of nephrology at the University of Washington in Seattle, and colleagues wrote. “To support a deeper understanding of the long-term outcomes of patients with advanced CKD who do not pursue dialysis, we performed a systematic review of longitudinal studies reporting survival, use of health care resources, quality of life and end-of-life care of patients with advanced CKD who did not pursue dialysis.”

The systematic review comprised of 41 cohort studies and 5,102 adults with advanced kidney disease who did not utilize dialysis. Researchers collected baseline data in addition to patterns of end-of-life care for patients who died during follow-up using a standardized data extraction form. Rather than meta-analyze data, researchers opted to synthesis the reported outcomes.

Among the 34 studies that provided information on survival, researchers found the range of medial survival was 1 to 41 months based on the baseline mean eGFR range of 7 mL/min/1.73 m² to 18 mL/min/1.73 m². Analyses revealed patients underwent approximately one to two hospital admissions, six to 16 in-hospital days, seven to eight clinical visits and two ED visits per year.

During a period of 8 to 24 months, researchers recorded improved mental well-being, and stable physical well-being and overall quality of life until late into patients’ illness.

Among patients who died before follow-ups, researchers observed that 20% to 76% enrolled in hospice, 27% to 68% died in a hospital and 12% to 71% died at home. Similarly, 57% to 76% of patients were hospitalized, and 4% to 47% underwent an invasive procedure during their final month of life.

Researchers noted more studies are needed to optimize the outcomes among patients who choose not to use dialysis.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced CKD is no care or death. 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. 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,” Wong and colleagues wrote. “These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, but they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”