Conservative Kidney Management: When, Why, and For Whom?

Deciding between dialysis and conservative kidney management (CKM) in an elderly or seriously ill person with kidney failure is complex and requires shared decision making. Patients and families look to their nephrologist to provide an individualized recommendation that aligns with patient-centered goals. For a balanced and considered decision to be made, dialysis should not be the default and nephrologists need to be familiar with relevant prognostic information including survival, symptom burden, functional trajectory, and quality of life with dialysis and with CKM. CKM is a holistic, proactive, and multidisciplinary treatment for kidney failure. For some elderly comorbid patients, CKM improves symptom burden and aligns with quality-of-life goals, with modest or no loss of longevity. CKM can be provided by a nephrologist alone but ideally is managed through partnership with a dedicated supportive or palliative care service embedded within the nephrology practice. Treatment decisions are best discussed early in the disease trajectory and occur over many consultations, and nephrologists should be upskilled in communication to better support patients and families in these important conversations. Nephrologists should remain actively involved in their patients' care through to end-of-life care.

Kidney failure end-of-life care: impact of advance care planning - retrospective observational study.

OBJECTIVES: Patients with kidney failure (KF) have poor prognosis yet receive aggressive medical interventions at the end of life. Advance care planning (ACP) aims to respect patients' treatment preference and facilitate good death, though whether these are achieved in KF is unknown.This study examines the utility of ACP for end-of-life care in KF patients. METHODS: A retrospective observational study of KF patients who completed an ACP document 2012-2019 and died in an Australian hospital. Medical records were reviewed to assess treatment concordance to the ACP document and quality of end-of-life care received. RESULTS: 65 KF patients (29 dialysis, 36 conservative) had a median age of 84 years and 57% males. 86% of deaths followed an emergency admission. ACP documents recorded patients' preference to avoid cardiopulmonary resuscitation (91%) and forego dialysis (86%). 95% patients received treatment concordant with ACP. One patient was resuscitated, and one conservative patient dialysed. A good quality death was achieved for most, including dialysis withdrawal (80%), palliative care referral (88%), discussion of prognosis (95%), rationalised medications (89%) and anticipatory end-of-life medications (92%). CONCLUSION: ACP documents are useful facilitating treatment concordant with KF patients' preferences. Most patients avoided aggressive medical interventions and received good quality end-of-life care.

Survival of Older Patients With Advanced CKD Managed Without Dialysis: A Narrative Review.

Shared decision making is important when deciding the appropriateness of dialysis for any individual, particularly for older patients with advanced chronic kidney disease who have high mortality. Emerging evidence suggests that patients with advanced age, high comorbidity burden, and poor functional status may not have any survival advantage on dialysis compared with those on a conservative kidney management pathway. The purpose of this narrative review is to summarize the existing studies on the survival of older patients with stage 4 or 5 chronic kidney disease managed with or without dialysis and to evaluate the factors that may influence mortality in an effort to assist clinicians with shared decision making. Median survival estimates of conservative kidney management patients are widely varied, ranging from 1-45 months with 1-year survival rates of 29%-82%, making it challenging to provide consistent advice to patients. In existing cohort studies, the selected group of patients on dialysis generally survives longer than the conservative kidney management cohort. However, in patients with advanced age (aged ≥80 years), high comorbidity burden, and poor functional status, the survival benefit conferred by dialysis is no longer present. There is an overall paucity of data, and the variability in outcomes reflect the heterogeneity of the existing studies; further prospective studies are urgently needed.

End-stage kidney disease: The last 12 months.

BACKGROUND: Chronic kidney disease (CKD) is increasingly prevalent in Australia's ageing population. Over the past decade, there has been growing recognition that dialysis does not benefit every patient with end-stage kidney disease (ESKD). Patients with advanced age, significant comorbidities and poor functional status may not gain a survival benefit with dialysis when compared with being managed conservatively. These developments have implications for general practitioners (GPs). A further development has been the emergence of renal supportive care, a patient-centred approach that integrates the principles of palliative care into nephrology. OBJECTIVE: The aim of this article is to outline salient aspects in the care of patients with ESKD. DISCUSSION: Salient aspects throughout the trajectory of ESKD are discussed, including symptoms of CKD, relevant management, prognostication, advance care planning discussions and end-of-life care. The role of the GP is vital, and it is recommended that GPs are involved early in a patient's CKD trajectory.

Prevalence of Taste Changes and Association with Other Nutrition-Related Symptoms in End-Stage Kidney Disease Patients.

OBJECTIVES: Gastrointestinal symptoms are common in end-stage kidney disease (ESKD) and have been associated with reduced health-related quality of life and malnutrition. The aim of this study is to describe the prevalence of taste changes in an ESKD population and to evaluate whether taste changes are associated with the presence or severity of other nutrition-related symptoms and malnutrition. METHODS: We conducted a retrospective audit of people with ESKD on conservative, nondialysis management or renal replacement therapy who had completed a taste change assessment. Taste change was assessed on a Likert scale from none to overwhelming. Descriptions of taste changes were also collected. Other outcomes included gastrointestinal symptoms collected using the iPOS-renal symptom inventory, nutritional status, and biochemical parameters. RESULTS: In total, 298 patients were included in our analysis. Taste changes were reported in 38% of this cohort. Taste changes were significantly associated with upper gastrointestinal symptoms (nausea, vomiting, anorexia, and dry/sore mouth) and malnutrition. CONCLUSIONS: Our findings indicate that taste changes are highly prevalent and probably under-recognized in ESKD. Further investigation of the association with malnutrition is needed. Future trials are needed to evaluate strategies to manage taste changes in this population.