Comprehensive Conservative Management Research Articles

The Quality of Life in Elderly Patients in Comprehensive Conservative Management or Hemodialysis: A Case-Control Study in Analogous Basal Conditions.

Comprehensive conservative management (CCM) is a viable treatment option for elderly patients with end-stage kidney disease (ESKD). However, it involves a significant change in dietary habits, such as adopting a low-protein diet. Therefore, it is crucial to understand its impact on the patient's quality of life (QoL), particularly when compared to hemodialysis (HD). The study aims to evaluate the differences in the QoL between patients undergoing CCM and HD. The study included 50 patients over 75 with ESKD, with 25 patients in the CCM group and 25 in the HD group. The CCM group followed a personalized low-protein diet, while the HD group did not have protein restrictions. Various parameters were assessed, including demographic data, urine output, blood tests, comorbidity index, Visual Analog Scale (VAS), and hospitalization. The SF-12 questionnaire assessed the QoL, and the Physical Composite Score (PCS) and Mental Composite Score (MCS) were calculated. The study revealed no age and comorbidity index differences between CCM and HD patients. In contrast, CCM patients reported significantly better physical and mental well-being than HD patients. In univariate analysis, CCM (B 0.24, p = 0.001), protein intake (B -0.004, p = 0.008), hospitalization (B -0.18, p = 0.024), urine output (B 0.25, p = 0.001), and VAS (B -0.26, p < 0.001) influenced the PCS. At the same time, only the type of treatment (B = 0.15, p = 0.048), urine output (B 0.18, p = 0.02), and VAS (B -0.14, p = 0.048) influence the MCS. In contrast, in multivariate analysis, only CCM contributed to an improved PCS (B 0.19, p = 0.003) and MCS (B 0.16, p = 0.03), while a higher VAS worsened the PCS (B -0.24, p < 0.001) and MCS (B -0.157, p = 0.0024). In elderly patients with similar basal conditions, health-related QoL perception is better in CCM than in HD patients.

The impact of population ageing on the burden of chronic kidney disease.

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

#3659 KIDNEY FAILURE MANAGEMENT IN THE ELDERLY: A PRELIMINARY SURVIVAL ANALYSIS

Abstract Background and Aims Dialysis treatment (DT) is the most common approach for patients with kidney failure. However, this may not be optimal for geriatric individuals, as more than half of elderly patients who initiate DT die within the first year. As a result, current guidelines advocate for presenting comprehensive conservative management (CM) as an alternative option for vulnerable patients and their families. A recent meta-analysis (2022) revealed that DT had a median survival time of 20-67 months, compared to 6-31 months for CM, indicating that individuals who opt for DT may have higher survival benefits. This distinction, however, disappears in +80 y/o patients, suggesting that both therapies may yield similar outcomes in this population. The efficacy of CM, however, remains poorly recognized due to the difficulty in comparing the treatments and the heterogeneous nature of the studies conducted. Therefore, our study aimed to investigate and compare the survival of the elderly who elected to undergo either conservative therapy or dialysis. Method We present a preliminary analysis of a prospective observational study conducted across 3 Nephrology Units (Veneto, Italy). We enrolled 117 patients in the pre-dialysis or CM clinics, meeting the eligibility criteria: ≥75 y/o, eGFR&amp;gt;15 ml/min/1.73 m2 (CKD-EPI formula), and had not already undergone DT or CM (personalized pharmacological therapy combined with a low-protein diet). At baseline, socio-demographic information, patient comorbidities, and blood and urine tests were collected through medical records and interviews. Additionally, the SF-36 questionnaire, the Barthel questionnaire, and the Mini-Mental State Examination assessed the quality of life, functional status, and global cognitive functioning. Survival was evaluated at 3 and 9 months after follow-up initiation, defined as the date of the first dialysis session or when the eGFR dropped below 10 ml/min/1.73 m2 in CM patients. The follow-up ended when patients reached the 9th month, died from any cause, switched treatments, discontinued medical follow-up, dropped out of the study voluntarily, or at the end of the project. To determine if any across-group differences existed at the baseline, non-parametric tests were used for continuous variables and the chi-square test for categorical variables. Kaplan-Meyer curve, Log Rank Test and Cox regression were performed for survival analysis. Results Of the 117 enrolled patients, 64 initiated the follow-up, 47 (59.6% M) in CM, and 17 (64.7% M) in DT. The patients in CM were older than those in DT (p = 0.028), with a median age of 82.5 (75.4-91.7) compared to 78.9 (75.6-87.9). At baseline, there were other statistically significant differences (p&amp;lt;0.05) in median levels of BUN, creatinine, PTH, haemoglobin, and total cholesterol. Comorbidities were similar in both groups. During the follow-up, 11 patients died (17.2%), 10 in CM (21.3%) and 1 in DT (5.9%). One patient in CM had an unavailable death date and was, therefore, excluded from further analysis. Kaplan-Meier curves and Log Rank Test revealed no significant difference in survival (p = 0.25). The median survival time was undefined, as over 50% of subjects in both groups did not experience the event during follow-up. In CM, unadjusted survival rates at 3 and 9 months were 91.3% and 78.2%, respectively. The effect of the therapies resulted in not significant after adjusting for important prognostic covariates. Conclusion In this study, we found that middle-term survival in the elderly is comparable to DT and CM. Despite limitations, these results provide valuable information for clinical decision-making. Our results suggest that well-organized CM can be a reasonable option for elderly patients with kidney failure.

MO690: Overview of Peritoneal Dialysis Outcomes in Northern Cyprus: A Nation-Based Study

Abstract BACKGROUND AND AIMS Prevalence of patients with end stage renal disease (ESRD) undergoing renal replacement therapies (RRT) is increasing worldwide (Stel et al. Supplemented ERA-EDTA Registry data evaluated the frequency of dialysis, kidney transplantation, and comprehensive conservative management for patients with kidney failure in Europe. Kidney Int. 2021;100(1):182–95 and Bikbov et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020; 395(10 225): 709–33). Epidemiology of ESRD and treatment options for these patients should be considered in health system planning (Bikbov et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020; 395(10 225):709–33). By an enhanced national PD program, more patients may have chance to take advantage of this treatment option. In this study we aim to investigate whether PD is preferred as first dialysis treatment modality in Northern Cyprus and to evaluate PD duration, and outcomes in order to improve PD program. METHOD PD patients aged above 18 years who were followed between 2003 and 2021 in Northern Cyprus were screened retrospectively. Demographic data, primary kidney diseases, comorbidities and previous RRT modalities were investigated. Episodes of peritonitis, transfer to automated PD in the follow-up, total duration on PD treatment, transfer to renal transplantation or HD and mortality rate were evaluated. Reasons for shifting from PD to HD were analysed. Outcomes of elderly (aged 65 years and above) and diabetic patients who were dropped out from PD were found out. RESULTS A total of 123 patients (33 female/90 male) aged 18–83 years were included to the study. A total of 25 patients were actively doing PD, 2 moved to another country on PD therapy and 96 dropped out of PD. A total of 40% of 123 PD patients initiated RRT with PD (Fig. 1). Median time was found 1 month in the rest of patients to transfer PD from other modalities. Sixteen (16.8%) patients had renal transplantation during follow-up. Thirty-three patients (34.7%) transferred to HD. Insufficient dialysis (40.7%) and PD-related infections (29.6%) were the most common reasons for shifting from PD to HD (Fig. 2). Forty-six (48.4%) patients were died on PD therapy at the age of 67 ± 11. Cardiovascular events (50%) and various infections (35%) were the leading causes of mortality. A total of 48 (43.2%) PD patients had at least one episode of peritonitis. Automated PD was used by 58 (53.2%) patients. PD duration was 36 (1–150) months in patients who were dropped out of PD. Total duration on PD treatment was longer for males than females. Total duration on PD treatment, initiation RRT with PD, prevalence of hypertension, diabetes mellitus (DM), peritonitis and use of automated PD were not significantly different between elderly (patients aged ≥ 65 years, n = 34) and younger individuals (18–65 years). Comorbidity index was found significantly higher in elderly group (P &amp;lt; 0.001). PD duration was longer for males then females (P = 0.044) and the duration was similar in patients with or without DM, in the dropped-out patients (P = 0.205). CONCLUSION A significant amount of patients (60%) required HD before initiation of PD. Early admission of patients to nephrology department and timely initiation of education program may contribute to decrease need of HD before PD (Briggs et al. International variations in peritoneal dialysis utilization and implications for practice. Am J Kidney Dis. 2019; 74(1): 101–10). As elderly patients had similar results with younger ones, age should not be considered as a challenging barrier for PD initiation. Precautions to prevent development of peritonitis, ultrafiltration failure and dialysis insufficiency may contribute to extent total duration on PD treatment.

Patient-reported factors influencing the choice of their kidney replacement treatment modality.

BackgroundAccess to various kidney replacement therapy (KRT) modalities for patients with end-stage kidney disease differs substantially within Europe.MethodsEuropean adults on KRT filled out an online or paper-based survey about factors influencing and experiences with modality choice (e.g. information provision, decision-making and reasons for choice) between November 2017 and January 2019. We compared countries with low, middle and high gross domestic product (GDP).ResultsIn total, 7820 patients [mean age 59 years, 56% male, 63% on centre haemodialysis (CHD)] from 38 countries participated. Twenty-five percent had received no information on the different modalities, and only 23% received information >12 months before KRT initiation. Patients were not informed about home haemodialysis (HHD) (42%) and comprehensive conservative management (33%). Besides nephrologists, nurses more frequently provided information in high-GDP countries, whereas physicians other than nephrologists did so in low-GDP countries. Patients from low-GDP countries reported later information provision, less information about other modalities than CHD and lower satisfaction with information. The majority of modality decisions were made involving both patient and nephrologist. Patients reported subjective (e.g. quality of life and fears) and objective reasons (e.g. costs and availability of treatments) for modality choice. Patients had good experiences with all modalities, but experiences were better for HHD and kidney transplantation and in middle- and high-GDP countries.ConclusionOur results suggest European differences in patient-reported factors influencing KRT modality choice, possibly caused by disparities in availability of KRT modalities, different healthcare systems and varying patient preferences. Availability of home dialysis and kidney transplantation should be optimized.

Results of the European EDITH nephrologist survey on factors influencing treatment modality choice for end-stage kidney disease.

BackgroundAccess to forms of dialysis, kidney transplantation (Tx) and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD) varies across European countries. Attitudes of nephrologists, information provision and decision-making may influence this access and nephrologists may experience several barriers when providing treatments for ESKD.MethodsWe surveyed European nephrologists and kidney transplant surgeons treating adults with ESKD about factors influencing modality choice. Descriptive statistics were used to compare the opinions of professionals from European countries with low–, middle– and high–gross domestic product purchasing power parity (GDP PPP).ResultsIn total, 681 professionals from 33 European countries participated. Respondents from all GDP categories indicated that ∼10% of patients received no information before the start of renal replacement therapy (RRT) (P = 0.106). Early information provision and more involvement of patients in decision-making were more frequently reported in middle- and high-GDP countries (P < 0.05). Professionals’ attitudes towards several treatments became more positive with increasing GDP (P < 0.05). Uptake of in-centre haemodialysis was sufficient to 73% of respondents, but many wanted increased uptake of home dialysis, Tx and CCM. Respondents experienced different barriers according to availability of specific treatments in their centre. The occurrence of barriers (financial, staff shortage, lack of space/supplies and patient related) decreased with increasing GDP (P < 0.05).ConclusionsDifferences in factors influencing modality choice when providing RRT or CCM to adults with ESKD were found among low-, middle- and high-GDP countries in Europe. Therefore a unique pan-European policy to improve access to treatments may be inefficient. Different policies for clusters of countries could be more useful.

Supplemented ERA-EDTA Registry data evaluated the frequency of dialysis, kidney transplantation, and comprehensive conservative management for patients with kidney failure in Europe

The aims of this study were to determine the frequency of dialysis and kidney transplantation and to estimate the regularity of comprehensive conservative management (CCM) for patients with kidney failure in Europe. This study uses data from the ERA-EDTA Registry. Additionally, our study included supplemental data from Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, Slovenia and additional data from Israel, Italy, Slovakia using other information sources. Through an online survey, responding nephrologists estimated the frequency of CCM (i.e. planned holistic care instead of kidney replacement therapy) in 33 countries. In 2016, the overall incidence of replacement therapy for kidney failure was 132 per million population (pmp), varying from 29 (Ukraine) to 251 pmp (Greece). On 31 December 2016, the overall prevalence of kidney replacement therapy was 985 pmp, ranging from 188 (Ukraine) to 1906 pmp (Portugal). The prevalence of peritoneal dialysis (114 pmp) and home hemodialysis (28 pmp) was highest in Cyprus and Denmark respectively. The kidney transplantation rate was nearly zero in some countries and highest in Spain (64 pmp). In 28 countries with five or more responding nephrologists, the median percentage of candidates for kidney replacement therapy who were offered CCM in 2018 varied between none (Slovakia and Slovenia) and 20% (Finland) whereas the median prevalence of CCM varied between none (Slovenia) and 15% (Hungary). Thus, the substantial differences across Europe in the frequency of kidney replacement therapy and CCM indicate the need for improvement in access to various treatment options for patients with kidney failure.

Health technology assessment in obstetrics: advantage of tailored conservative strategy vs surgical therapies of monochorionic twin complicated by TRAP-sequence

Introduction.Twin reversed arterial perfusion (TRAP) syndrome is one of the types of complications of monochorial twins (MT) with a frequency of occurrence of 1:35000 births. It is characterized by the presence of the main vessel instead of a normal 4 chambers heart and intrauterine developmental abnormalities. This pregnancy requires monitoring using dynamic ultrasound diagnostics every 7 days, in accordance with current recommendations. The treatment is intrauterine laser coagulation of blood vessels of the “acardial fetus” (AP) in order to prevent the development of a threatening condition for the “fetal pump” (PP). Aim: to demonstrate the possibilities of comprehensive conservative management of monochorial pregnancy complicated by TRAP.Materials and methods. An ultrasound examinations were performed on a weekly basis in monochorionic pregnancy, complicated by TRAP within the period 12-38 weeks. Serum concentrations of biochemical markers PAPP-A (pregnancy-associated plasma protein-A) and β-hGC (β-subunit of human chorionic gonadotropin) were studied in the first trimester to predict adverse perinatal outcomes.Results. The possibility of prolonging a pregnancy complicated by TRAP without performing intrauterine surgical intervention, during which quite serious complications can occur in this category of pregnancies, has been demonstrated. In a patient with monochorionic twins complicated by TRAP, totally 27 ultrasound examinations were performed within the period 12-38 weeks. This approach made it possible to dynamically monitor the condition of a pregnant and healthy fetus and to prolong pregnancy without surgery until the full term.Conclusions.Following the existing guidelines, without tailoring for individual risk, may lead to an unreasonable increase in surgical interventions. In turn, surgery is not only accompanied by a high risk of complications (up to 15%), but also constitute a certain financial burden on the budget, determined by the state on the level of 208,000 rubles. Performing routine ultrasound examinations according to the examination protocol for monochorionic pregnancy will contribute to avoiding the complications associated with surgery and better selection for surgery as well as reducing the government costs.

Non-medical barriers reported by nephrologists when providing renal replacement therapy or comprehensive conservative management to end-stage kidney disease patients: a systematic review.

BackgroundLarge international differences exist in access to renal replacement therapy (RRT) modalities and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD), suggesting that some patients are not receiving the most appropriate treatment. Previous studies mainly focused on barriers reported by patients or medical barriers (e.g. comorbidities) reported by nephrologists. An overview of the non-medical barriers reported by nephrologists when providing the most appropriate form of RRT (other than conventional in-centre haemodialysis) or CCM is lacking. MethodsWe searched in EMBASE and PubMed for original articles with a cross-sectional design (surveys, interviews or focus groups) published between January 2010 and September 2018. We included studies in which nephrologists reported barriers when providing RRT or CCM to adult patients with ESKD. We used the barriers and facilitators survey by Peters et al. [Ruimte Voor Verandering? Knelpunten en Mogelijkheden Voor Verbeteringen in de Patiëntenzorg. Nijmegen: Afdeling Kwaliteit van zorg (WOK), 2003] as preliminary framework to create our own model and performed meta-ethnographic analysis of non-medical barriers in text, tables and figures. ResultsOf the 5973 articles screened, 16 articles were included using surveys (n = 10), interviews (n = 5) and focus groups (n = 1). We categorized the barriers into three levels: patient level (e.g. attitude, role perception, motivation, knowledge and socio-cultural background), level of the healthcare professional (e.g. fears and concerns, working style, communication skills) and level of the healthcare system (e.g. financial barriers, supportive staff and practice organization).ConclusionsOur systematic review has identified a number of modifiable, non-medical barriers that could be targeted by, for example, education and optimizing financing structure to improve access to RRT modalities and CCM.

The Cognitive decline in Older Patients with End stage renal disease (COPE) study – rationale and design

Background: Older patients with end stage renal disease (ESRD) are at increased risk for cognitive decline, but detailed studies of the magnitude of cognitive decline on dialysis or comprehensive conservative management (CCM) are lacking and the underlying pathophysiological mechanisms have poorly been studied.Objectives: To describe the rationale and design of the COPE study. Study objectives are as follows. Firstly, to examine the severity of cognitive impairment in older patients reaching ESRD before dialysis and the rate of decline after dialysis or CCM initiation. Secondly, to study the association of blood biomarkers for microvascular damage and MRI derived measurements of small vessel disease with the rate of cognitive decline. Thirdly, to examine to what extent cardiac function is related to brain structure and perfusion in patients reaching ESRD. Finally, to study the association of cognitive and functional capacity with quality of life in pre-dialysis patients, as well as after dialysis or CCM initiation.Study design and methods: The COPE study is a prospective, multicenter cohort study in the Netherlands, including prevalent and incident pre-dialysis patients ≥65 years old with eGFR ≤20 ml/min/1.73 m2, awaiting either dialysis or CCM initiation. At baseline extensive data is collected including a comprehensive geriatric assessment and laboratory tests. Brain and cardiac MRI for analysis of structural and functional abnormalities are performed at baseline and repeated following therapy change. All other measurements are repeated annually during four years of follow up, including an extra evaluation six months after initiation of dialysis.Conclusions: Knowledge of the magnitude of cognitive decline and its underlying pathophysiological mechanism, as well as its impact on functionality and quality of life can eventually help to postulate an algorithm for well balanced decision making in treatment strategies in older patients reaching ESRD.Clinical trial registration: The COPE study is registered on www.ccmo.nl (number: NL46389.058.13).

Supportive Care: Comprehensive Conservative Care in End-Stage Kidney Disease.

Comprehensive conservative (nondialytic) kidney care is widely recognized and delivered but until recently, has not been clearly defined. We provide a clear definition of comprehensive conservative care. This includes interventions to delay progression of kidney disease and minimize complications as well as detailed communication, shared decision making, advance care planning, and psychologic and family support. It does not include dialysis. Limited epidemiologic evidence from Australia and Canada indicates that, for every new person diagnosed with ESRD who receives dialysis or transplant, there is one new person who is managed conservatively (either actively or not). For older patients (those >75 or 80 years old) who have higher levels of comorbidity (such as diabetes and heart disease) and poorer functional status, the survival advantage of dialysis may be limited, and comprehensive conservative management may be considered; however, robust comparative evidence remains limited. Considerations of symptoms, quality of life, and hospital-free days are as or sometimes more important for patients and families than survival. There is some evidence that communication about possible conservative management options is generally insufficient, even where comprehensive conservative care pathways are already established. Symptom control and the cost-effectiveness of interventions are addressed in the companion papers within this Moving Points in Nephrology series. There is almost no evidence about which models of care and which interventions might be most beneficial in this population; future research on these areas is much needed. Meanwhile, consistency in definition of comprehensive conservative care and basing interventions on existing evidence about survival, symptoms, quality of life, and experience will maximize patient-centered and holistic care.

Chondromalacia patellae in athletes

A comprehensive conservative management program for chondromalacia patella in athletes has been presented. The clinical manifestations and the efficacy of conservative treatment have been documented in the prospective study of 100 consecutive athletes. The over-all success rate was 82%, and 18% were considered to be failures of conservative treatment. Only 8 of these 100 athletes have required surgical treatment. It was concluded that this type of conservative management is effective in the majority of athletes with symptomatic patellofemoral syndromes, and that surgical treatment should be necessary for only the relative few who fail to respond to an adequate trial of conservative treatment.