Blog entry by Arif Khwaja
There is some interesting data published from Stevenage, England in this months cJASN describing differences in outcomes between patients on RRT and those opting Conservative Kidney Management (CKM). Observational data from the UK has already shown that in those elderly patients with significant co-morbidity RRT offers litlle survival advantage over CKM. Furthermore data from the Royal Free Hospital, London had suggested that much of the survival advantage that such comorbid patients get from RRT is at the price of days spent in hospital and the actual, 'hospital-free' days gained was marginal. Whats interesting about the current study is that it focuses on endpoints that matter to patients - namely objective quality of life measures using tools such as SF-36 and Hospital Anxiety and Depression Scale on a 3 monthly basis in a cochort of patients with CKD4/5. In their cohort of 170 patients 30 elected for CKM. Unsurprisingly these patients had more comorbidities and poorer functional status. Serial quality of life measures demonstrated no change from baseline EXCEPT a decline in life satisfaction associated with those starting dialysis. Median survival (after adjustment for comorbidity) was 13 months shorter in the CKM group.
Of course this data is observational and subject to signficant confounding bias but then there is never going to be an RCT comparing outcomes between RRT and CKM.
However it adds to what we already know - patients with poor functional status or comorbidity get little benefit from RRT either in terms of survival or quality of life. Making individual patient decisions about RRT is very difficult but in the UK, NHS kidney care have lauched an online decision aid to help patients make decisions about RRT ( see http://sdm.rightcare.nhs.uk/pda/established-kidney-failure/)... the decision aid incorporates the values and aspirations of individual patients to help them come to a decision and will hopefully help decision making in the UK.
Its important to bear in mind that this kind of data is almost certainly irrelevant for those practicing in emerging countries as the patient population and social care will be very different making it impossible to extrapolate such data to those countries. I am struck that in certain parts of the world there seem to be cultural barriers to CKM even though in selected cases it appears associated with a better quality of life and equivalent survival. The key here is to get *LOCAL* data starting probably with survival data for those starting RRT as accurate information is essential to help patients make decisions. Without that any discussions of the pros and cons of RRT are meaningless......
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2. Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity. Chandna SM, Schulz J, Lawrence C, *Greenwood* RN, *Farrington K*. BMJ. 1999 Jan 23;318(7178):217-23.
3. Is maximum *conservative* management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?Carson RC, Juszczak M, Davenport A, *Burns A*.Clin J Am Soc Nephrol. 2009 Oct;4(10):1611-9.
4. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage Murtagh FE, Marsh JE, Donohoe P, *Ekbal NJ*, Sheerin NS, Harris FE. Nephrol Dial Transplant. 2007 Jul;22(7):1955-62.
5. Conservatively managed patients with stage 5 chronic kidney disease--outcomes from a single center experience.Ellam T, *El-Kossi M*, Prasanth KC, El-Nahas M, Khwaja A. QJM. 2009 Aug;102(8):547-54