This systematic review demonstrates that conservative, nondialytic management of ESRD is a viable option in certain patients. For the elderly and patients with multiple comorbid conditions, dialysis does not always offer a survival advantage. Five prognosis studies in this review included both conservative management and dialysis patients; three of these studies found a statistically significant survival benefit with dialysis, but the other two found no difference. Patients with multiple comorbid conditions, especially ischemic heart disease, were the least likely to experience a survival benefit.
Future research could develop clinical tools to predict which patients will survive longer with dialysis versus conservative management. Several models already exist to predict survival on dialysis,32–34
but similar models have not yet been developed for conservative management. In the meantime, physicians must rely on clinical judgment and the preliminary results presented in this review. If dialysis is not expected to prolong life due to extremely advanced age or comorbid conditions, patients and families should receive counseling to ensure that their expectations are realistic.35
Even when dialysis can be expected to prolong survival, the burdens of dialysis (cost, infections, vascular access issues, fluctuating blood pressure) deserve careful consideration. The prognosis study by Carson et al. included additional analyses of hospitalization rates and location of death21
Dialysis patients spent a greater proportion of days in the hospital compared with conservative management patients (25 versus 16 days per patient per year). Conservative management patients were four times more likely to die at home or in a hospice (OR 4.15; 95% CI 1.67 to 10.25). Routine outpatient hemodialysis is also extremely time consuming. Thus, while patients may live longer with dialysis, they can expect to spend a significant proportion of that time in a medical setting. Patients and families differ in how they prioritize prolonging life versus maximizing time at home; these preferences are important to elicit when discussing dialysis initiation.
There are several limitations to the conclusions from this systematic review. As already mentioned, the literature in this field is widely dispersed and difficult to target with database search strategies. We believe that we overcame this limitation through multiple other methodologies to locate articles, but it is possible that a study was missed.
The prognosis studies exhibit significant variability in inclusion criteria, resulting in heterogeneous study populations. In addition, different starting points were used in the measurement of survival (decision not to initiate dialysis, proposed date of first dialysis, first measurement of glomerular filtration rate (GFR) ≤10.8, and first measurement of GFR <
15). These factors contribute to the wide variability in reported survival. While this variability makes it more difficult to counsel individual patients about what to expect with conservative management, this systematic review provides at least a starting point for discussion.
The results of this review may not be generalizable to nursing home residents, a growing subset of the population; patients in the included studies were recruited from ambulatory clinics and were cognitively intact. Nursing home residents have especially poor outcomes on dialysis with a mortality rate of 58% in the first year.36
Pre-dialysis functional status is maintained in only 13% of nursing home residents after one year on dialysis.36
Comparable data for conservative management is needed to fully inform discussions about dialysis initiation in this population.
It is clear that conservatively managed patients have many symptoms. Unfortunately, none of the symptom studies conducted a head-to-head comparison of conservative management versus dialysis. It is possible that patients on dialysis have similarly high symptom burden; additional research is needed to address this question. In the meantime, patients considering conservative management should be informed of the high incidence of various symptoms and then reassured that aggressive symptom management will be part of their care. A recent longitudinal cohort study found that functional status with nondialytic management remains relatively constant until the last month of life.37
A second study of conservative management found an increase in symptom distress and health related concerns in the last two months of life.38
The findings presented on QOL are limited and preliminary. The included studies compare small groups of patients, and the results are not stratified by age or comorbidities to allow more precise determination of which patients benefit from dialysis in terms of QOL. Larger head-to-head studies would allow qualitative and quantitative QOL analyses to guide patient decision making. Ideally, comparative data about both survival and QOL would be presented when counseling patients about dialysis versus conservative management.
New evidence suggests that delayed initiation may also be a safe alternative in patients who ultimately choose dialysis. A recent trial randomized 828 patients to dialysis initiation when their GFR reached 10.0 to 14.0
ml per minute (early start) or when their GFR reached 5.0 to 7.0
ml per minute (late start).39
During a median follow-up period of 3.59 years, there was no significant difference between groups in mortality or the frequency of adverse events. Initiating dialysis later in the disease course would give patients and physicians additional time to determine whether dialysis is the best treatment option.
For patients who opt for conservative management, guidelines are needed to determine the best clinical practices in nondialytic management. Most nephrologists currently extrapolate fluid and electrolyte management from earlier-stage CKD. Several centers are starting to develop specialized renal palliative care teams to provide concurrent renal care and symptom management for patients who decline or discontinue dialysis.40–42
These multidisciplinary teams typically include nurses, social workers, and physicians from both nephrology and palliative care. Preliminary data suggests that they are successful in managing symptoms40
and providing for advanced care planning and family support.42
ESRD represents a growing opportunity to offer palliative care to a nonmalignant disease with extensive end-of-life care needs.
Finally, the results of this review demonstrate that failure to initiate dialysis is fundamentally different from the withdrawal of dialysis in which imminent death is expected. Patients can live for months or even years after deciding not to start dialysis. Patients and clinicians who are familiar with dialysis withdrawal may assume that failure to initiate dialysis is analogous to stopping dialysis. Educational efforts targeting patients, primary care physicians, and the renal community are needed to raise awareness about conservative management as an acceptable alternative.