When Should Those With End-Stage Kidney Disease Forego Dialysis?
By Mitchel L. Zoler, PhD
The role of older age as a trigger for considering conservative kidney management instead of dialysis is especially relevant because increasingly it's older patients who are developing ESKD, especially in the United States and other industrialized countries.
The chronic kidney management program for patients with end-stage kidney disease in Australia began in 2009 (the first chronic kidney management programs started in the UK a few years earlier). But the US is way behind.
"Patients more than 75 years old form the fastest-growing group. It is striking how many elderly patients we now treat with dialysis," said Susan P.Y. Wong, MD a nephrologist with the VA Puget Sound Health Care System and the University of Washington in Seattle, who has studied conservative kidney management use in US practice.
A Patient Scenario for Opting Out of Dialysis
Brown offered this scenario of a typical chronic kidney management case that he sees: An 84-year-old man with an estimated glomerular filtration rate (eGFR) of 16 mL/min/1.73m2 and with diabetes and heart failure who, following a shared decision-making process with his clinicians, wife, and daughter, opts for chronic kidney management rather than starting dialysis. To formalize the decision a chart entry for the patient spells out that dialysis is no longer an option.
Brown said the patient "and his family know from the outset that his median survival is about 14 months. We manage him as much as possible with clinic visits and home visits by nurses, and as he reaches his final phase, we either manage him at home with support from our community palliative care team or he goes to a hospice."
Becoming hospitalized at this point is possible but is less common than eventual death at home or in hospice.
Room for Improvement in the US
Whereas a shared decision determines which patients with ESKD go to dialysis and which to conservative kidney management at Brown's program in Sydney and in programs elsewhere in Australia, the UK, Europe, and Canada, Wong outlined the current situation in the US.
In a 2016 study that she led using data from the national VA system, among more than 19,000 VA patients who had an eGFR of less than 15 mL/min/1.73m2 (a threshold commonly applied for starting dialysis) just 1 out of 7 (15%) f these patients did not start dialysis "even among the oldest patients with the highest comorbidity burden," she noted.
"I suspect the rate is even lower in other US healthcare systems," Wong said.
She noted that during her nephrology training about a decade ago, she received no exposure to the topic of conservative kidney management.
Without training, "conversations with patients and their family about goals-of-care and advanced-care planning make providers anxious," said Wong. "The conversations are charged with a lot of grief."
Wong also published a study in 2019 that focused on interviews with 21 nephrologists experienced in treating patients with ESKD who decided to not start dialysis. She and her co-authors concluded that "far-reaching changes" in culture, practice, and infrastructure are first needed to support more widespread delivery of conservative nephrology care to US patients with ESKD.
Despite Wong's interest in this topic, she notes, "we do not have a dedicated conservative kidney management program at the University of Washington. Each nephrologist makes it up as they go," she explained.