Abstract
Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.
Highlights
Chronic kidney disease (CKD) is a global public health issue.[1]
We review the historical evolution of guidelines about renouncement of renal replacement therapy (RRT) and palliative care, and highlight the absence of specific recommendations in Brazil
Many factors have contributed to the increase in the number of individuals diagnosed with CKD, including the evident association between CKD and poverty and unhealthy living conditions; the growing incidence of the main underlying causes of the disease, namely diabetes and hypertension; and, paradoxically, the greater availability of diagnostic methods and increased awareness of physicians and the general public over CKD
Summary
Chronic kidney disease (CKD) is a global public health issue.[1] Many factors have contributed to the increase in the number of individuals diagnosed with CKD, including the evident association between CKD and poverty and unhealthy living conditions; the growing incidence of the main underlying causes of the disease, namely diabetes and hypertension; and, paradoxically, the greater availability of diagnostic methods and increased awareness of physicians and the general public over CKD. Given that circumstances in developed nations may very well manifest in Brazil,[8] it is quite likely that the number of individuals on RRT in the country will increase substantially, including frail elderly subjects with an extensive list of comorbidities This observation underlines the difficulties inherent to establishing limits and parameters for the acceptance of dialysis, notably among elderly patients with slim chances of attaining functional recovery to a level that would allow them to survive for a relatively short period with minimal quality of life. The entanglement of technical, ethical, legal, cultural, and economic issues present in this dilemma still fills the minds of practitioners of Nephrology with questions and doubt
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