Quality of Life and Survival in Patients with Advanced Kidney Failure Managed Conservatively or by Dialysis

TLDR

Dialysis benefits for elderly patients with advanced kidney failure are uncertain, and some choose conservative kidney management instead. The study prospectively compared quality of life and survival between patients opting for dialysis and those choosing conservative kidney management. A cohort of 170 advanced CKD patients was followed for up to three years, with quality‑of‑life assessments every three months and documentation of dialysis initiation (80 HD, 44 PD, 30 CKM, 16 undecided). CKM patients were older, more comorbid, and had poorer physical health and higher anxiety, but mental health and life satisfaction were comparable to dialysis patients; quality of life remained stable over time, except life satisfaction declined after dialysis initiation, and median survival was 13 months shorter for CKM (1317 days for HD vs 913 days for CKM).

Abstract

Benefits of dialysis in elderly dependent patients are not clearcut. Some patients forego dialysis, opting for conservative kidney management (CKM). This study prospectively compared quality of life and survival in CKM patients and those opting for dialysis.Quality-of-life assessments (Short-Form 36, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale) were performed every 3 months for up to 3 years in patients with advanced, progressive CKD (late stage 4 and stage 5).After 3 years, 80 and 44 of 170 patients had started or were planned for hemodialysis (HD) or peritoneal dialysis, respectively; 30 were undergoing CKM; and 16 remained undecided. Mean baseline estimated GFR ± SD was similar (14.0 ± 4.0 ml/min per 1.73 m(2)) in all groups but was slightly higher in undecided patients. CKM patients were older, more dependent, and more highly comorbid; had poorer physical health; and had higher anxiety levels than the dialysis patients. Mental health, depression, and life satisfaction scores were similar. Multilevel growth models demonstrated no serial change in quality-of-life measures except life satisfaction, which decreased significantly after dialysis initiation and remained stable in CKM. In Cox models controlling for comorbidity, Karnofsky performance scale score, age, physical health score, and propensity score, median survival from recruitment was 1317 days in HD patients (mean of 326 dialysis sessions) and 913 days in CKM patients.Patients choosing CKM maintained quality of life. Adjusted median survival from recruitment was 13 months shorter for CKM patients than HD patients.