Shared Decision Making in Older Patients with Advanced Chronic Kidney Disease

Abstract

Background

The shared decision making (SDM) process when deciding the appropriateness of dialysis for an older individual with advanced CKD can be complex and challenging. There is a paucity of data on the survival, symptoms and quality of life of patients on a conservative non-dialytic kidney management (CKM) pathway. Furthermore, prognostication in these patients is difficult as existing predictive tools for mortality have not been extensively validated in the elderly CKD population. Chapter 1 provides a detailed literature review.

Aims and Methods

This aims of this research was to assist clinicians in the shared decision-making process by:

Providing data that clinicians and patients desire to know when making treatment decisions about the appropriateness of dialysis for an older individual: exploring survival, symptom burden and hospitalisation rates (Chapter 2). Assessing the utility and applicability of existing prognostication tools in the older CKD population (Chapter 3). We conducted a single-centre observational study on patients aged ≥65 years at St George Hospital, Sydney. Survival was analysed with Kaplan Meier Survival curves and Cox proportional hazard models. Symptom burden and hospitalisation rates were evaluated using linear mixed modelling. Validation of existing predictive tools for mortality were performed using logistic regression and calculation of the Hosmer-Lemeshow statistic.

Results and Conclusion

Older patients with advanced CKD have high mortality, comorbidity and symptom burden. In CKM patients, median survival was 15 and 8 months from the time their estimated glomerular filtration rate (eGFR) fell to 15 and 10ml/min/1.73m2 respectively. Survival from the time of modality choice or dialysis initiation was 14 months in the CKM and 53 months in the dialysis group. Survival was longer for dialysis cohort from all time points (p<0.001). Factors that reduced survival included higher comorbidities, poor nutritional status and heart failure. The symptom burden of most CKM patients improved by their 3rd clinic visit when managed by a multidisciplinary Renal Supportive Care program and unplanned hospitalisation rates were 2-fold lower compared to the dialysis cohort. Existing prognostication tools performed poorly in our study cohort. More studies are needed in this area.

These data should assist clinicians in the shared decision-making process.