Abstract
A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004–2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.
Highlights
Pre-dialysis education programmes are in widespread use across the renal community [1, 2]
Most outcome studies and registry data have focussed on what happens to patients from the time of commencing renal replacement therapy (RRT) resulting in a paucity of data on the outcomes of patients who have made a choice but not yet started treatment or chosen maximum conservative care (MCM) [9,10,11]
We aimed to explore how patient characteristics influenced whether patients chose to receive RRT (in-centre haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD) or Exploring the choices and outcomes of older patients with advanced kidney disease pre-emptive transplant) or opted for maximum conservative management (MCM)
Summary
Pre-dialysis education programmes are in widespread use across the renal community [1, 2]. Informing patients through a shared decision-making process can influence patient treatment decisions and improve outcomes [3, 4]. Most outcome studies and registry data have focussed on what happens to patients from the time of commencing renal replacement therapy (RRT) resulting in a paucity of data on the outcomes of patients who have made a choice but not yet started treatment or chosen maximum conservative care (MCM) [9,10,11].
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