How Long Can You Live With Stage 5 Kidney Disease

February 14, 2022 Post a Comment

Abstract

B ackground . Elderly patients with end-stage renal affliction and astringent extra-renal comorbidity accept a poor prognosis on renal replacement therapy (RRT) and may opt to exist managed conservatively (CM). Information on the survival of patients on this mode of therapy is express.

Methods. We studied survival in a large cohort of CM patients in comparison to patients who received RRT.

Results. Over an eighteen-year flow, we studied 844 patients, 689 (82%) of whom had been treated past RRT and 155 (18%) were CM. CM patients were older and a greater proportion had high comorbidity. Median survival from entry into phase 5 chronic kidney disease was less in CM than in RRT (21.2 vs 67.1 months: P < 0.001). All the same, in patients aged > 75 years when corrected for historic period, loftier comorbidity and diabetes, the survival advantage from RRT was ~ 4 months, which was non statistically meaning. Increasing age, the presence of loftier comorbidity and the presence of diabetes were contained determinants of poorer survival in RRT patients. In CM patients, however, age > 75 years and female person gender independently predicted ameliorate survival.

Conclusions. In patients aged > 75 years with loftier extra-renal comorbidity, the survival advantage conferred past RRT over CM is likely to be small. Age > 75 years and female person gender predicted amend survival in CM patients. The reasons for this are unclear.

Introduction

Twenty-5 years ago, a landmark publication drew attending to the rationing of access to renal replacement therapy (RRT) in the UK [i]. In 1981, simply 26.seven new patients per million population (pmp) had been accepted into RRT programmes in the United kingdom of great britain and northern ireland, in dissimilarity to 42.3 pmp in France and > sixty pmp in the Usa. Rationing was about striking in those aged ≥ 45 years. Following these revelations, at that place was a welcome liberalization of admission to RRT, fuelling a dramatic increase in acceptance rates, mirroring those beyond the adult globe. In the early on years of the new millennium, the incidence rates in the UK, like those in Northern Europe, stabilized at ~ 110 pmp, though far below those in the Usa currently at 361 pmp [2–4]. As a result, RRT populations throughout the developed world have expanded rapidly, the fastest growth occurring in the elderly, many of whom are dependent, and frail.

The benefits of dialysis for elderly, dependent patients with end-phase renal disease (ESRD), who often take multiple extra-renal comorbidities, have been questioned. The prospects for rehabilitation in such patents tend to be slim, and prognosis is often poor [5,6]. Dialysis in such circumstances can pose huge additional burdens for patients and their carers. The exercise of withholding dialysis in such circumstances has been common [7–9]. In recent years, the concept of the conservative direction programme has gained sway in an attempt to provide a comprehensive package of care to patients who have called to forego dialysis. Conservative management of ESRD involves a shift from efforts to prolong life to those which focus on intendance, quality of life and symptom control. Control of fluid and electrolyte balance, anaemia management by use of erythropoietin if need be, the provision of advisable end-of-life intendance and ongoing support for the patient and family/carers are important aspects [10]. The concept has been embodied as a switching focus from curing to caring, though the notion of cure in the context of ESRD may exist stretching the point [11].

It is important to distinguish this rational and appropriate utilise of therapies from the rationing arroyo referred to in a higher place. Rationing in this context refers to the limiting of access to expensive medical interventions in society to control the utilise of resources. A rational or appropriate approach refers to foregoing therapies in circumstances in which their apply is likely to be futile or detrimental to patient well-beingness.

A number of studies have described the upshot of conservative kidney direction [10,12–17]. In the comparative studies, dialysis for elderly patients with high comorbidity did not confer a significant survival advantage over conservative direction [x,12], at least in terms of hospital-free days [13]. In all these studies, the numbers of patients treated past conservative kidney management were small and follow-up relatively short. We studied a large series of conservatively managed patients and compared survival to those of a contemporaneous grouping of RRT patients. We also studied the predictors of survival in both groups.

Materials and methods

Patients

We reviewed the computerized records of all patients who had attended our nephrology clinics with progressive chronic kidney disease (CKD). We selected for further study all patients who had progressed every bit far as phase 5 CKD based on eGFR estimated by MDRD-4 equation. This was over an eighteen-year period to Baronial 2008. To run across this criterion, each patient had:

At least one value of eGFR in the range 10–15 mL/min/1.73 mⁱⁱ
All subsequent recorded values of eGFR < 15 mL/min/1.73 m²

Nosotros examined detailed computerized records and the case notes for all patients included in the study.

Survival in all patients was calculated from the date of the outset recorded value in stage five CKD every bit outlined to a higher place. Patients who presented in advanced stage 5 CKD (eGFR < ten) were not included since the unavailability of the date at which they reached stage v CKD fabricated it impossible to estimate survival time from entry to phase 5.

Patients were categorized into RRT patients or conservatively managed patients. Patients were designated equally RRT patients if they:

Subsequently commenced on dialysis either haemodialysis (HD) or peritoneal dialysis (PD)—OR
Subsequently underwent pre-emptive transplantation—OR
Had made a decision to embark dialysis and had begun preparations for this, often involving the creation of an A-Five fistula, just had died before dialysis initiation.

Patients were designated as conservatively managed if they had fabricated a determination to forego dialysis, should their kidney failure proceed to progress.

Modality choice

We aimed to offer patients a costless choice of modality constrained only by clinical and social imperatives. After the diagnosis of progressive CKD, patients were referred by the nephrologists to a liaison team, led by a senior nurse and a renal counsellor. This referral commonly took place when the patient had stage four CKD—but for a minority of patients this was sometimes later. The role of the team included assessment, instruction, counselling and support of the patient and family/carer before, during and afterward modality option. This process included a number of interviews with each patient and meaning others and at to the lowest degree one visit to the patient'due south abode. Afterwards subsequent discussions inside the multidisciplinary team, treatment options were discussed with each patient and significant others and an individualized treatment program formulated. Some patients with low comorbidity chose CM when the chances of survival could have been college on RRT. They were specifically counselled on the potential benefits of RRT, just their final decision was respected.

Bourgeois management programme

Patients opting for bourgeois direction were offered ongoing support by the multidisciplinary team in liaison with customs, master intendance and hospice services. Full medical treatment was continued, which included the employ of erythropoietin as advisable to care for or prevent anaemia.

Dialysis plan

HD patients were treated exclusively using high-flux membranes, predominantly polysulphone. Around twoscore% of patients were treated by online haemodiafiltration (HDF). Bicarbonate was used exclusively as the buffer, and ultrapure water was standard. Target total two-puddle Kt/V urea (Kt/V_Total) was one.2 per session for thrice-weekly Hard disk drive and HDF. PD patients were treated by continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis. Disconnect systems were used exclusively for CAPD. Minimum weekly Kt/V_Total target for both PD modes was two.0.

Data nerveless

The following data was obtained on all study patients from contemporaneous case notes and computer records:

Appointment of entry into phase five CKD—defined as the date of the first value of eGFR in the range ten–fifteen mL/min/1.73 yardⁱⁱ.
Age—at entry into stage 5 CKD [see (i)]
Gender
Ethnicity—defined equally white/non-white
Presence of diabetes mellitus
The presence and severity of extra-renal comorbidity. Patients were scored on the number and severity of the following atmospheric condition: cardiac disease, peripheral vascular disease, cerebrovascular affliction and respiratory disease. The severity of these diseases was scored every bit 0 = none, ane = minimal, 2 = mild, 3 = moderate and iv = avant-garde. Cancer was also graded (1–4) co-ordinate to its activity and nature (medium-term survival). Cirrhosis was scored as a 4. Scores were summed to form a combined comorbidity score [5]. A score of > four was graded as 'high' and a score ≤ iv was deemed every bit 'low'.
Serum creatinine level and eGFR (calculated by the MDRD-4 equation), at the time of entry into stage five CKD [see (i)]
Date of expiry

Statistical analysis

Groups were compared, using unpaired t-tests and chi-foursquare tests as advisable, with respect to age, gender ratio, ethnicity (white vs non-white), the proportion with diabetes mellitus, comorbidity severity score and eGFR on entry into stage five CKD. The Kaplan–Meier method was used to compare the survival fourth dimension between different groups. Differences were assessed using the log-rank exam. We used Cox proportional hazards model to decide the predictors of survival. We used SPSS version xviii for all statistical analyses.

Results

The total number of patients selected for study was 844, 689 (82%) of whom had been treated by RRT and 155 (xviii%) had been managed conservatively. The RRT grouping included 18 patients (2.six% of the RRT group) in whom dialysis had been planned, just died earlier dialysis initiation. Using intention-to-treat assay, these 18 patients were included in all analyses. Patients who received conservative treatment were significantly older than those treated past RRT, and a much greater proportion of them had high comorbidity (Tabular array 1). RRT and conservatively managed patients did not differ with respect to the distribution of gender or ethnicity (white vs non-white), nor with respect to the prevalence of diabetes. Estimated GFR at the onset of the study period was as well similar in RRT and conservatively managed groups (Table ane). Patients with severe comorbidity started dialysis at a significantly higher mean eGFR compared to those with low comorbidity (viii.71, SD two.58 vs viii.03, SD 2.54; P = 0.017).

Tabular array i

Demographic and clinical details of patients treated by dialysis and conservative kidney direction

	Bourgeois	Dialysis	P-value
Number	155 (18%)	689 (82%)
Age at stage v (years)	77.5 ± 7.6	58.5 ± xv.0	< 0.001
% > 75 years	68.4	11.two	< 0.001
% Male	59.4	66.half dozen	NS
% Not-white	14.2	fifteen.vii	NS
% Diabetes	35.5	34.3	NS
% Loftier comorbidity	49.seven	17.3	< 0.001
eGFR at phase five (mL/min/one.73 m²)	xiii.2 ± 1.four	13.ii ± 1.four	NS

	Bourgeois	Dialysis	P-value
Number	155 (18%)	689 (82%)
Age at stage v (years)	77.5 ± vii.half-dozen	58.5 ± 15.0	< 0.001
% > 75 years	68.4	11.2	< 0.001
% Male	59.iv	66.6	NS
% Not-white	14.2	xv.7	NS
% Diabetes	35.v	34.3	NS
% High comorbidity	49.7	17.3	< 0.001
eGFR at phase 5 (mL/min/1.73 thousand²)	13.2 ± i.four	13.2 ± 1.iv	NS

Table i

Demographic and clinical details of patients treated by dialysis and conservative kidney management

	Conservative	Dialysis	P-value
Number	155 (18%)	689 (82%)
Age at phase 5 (years)	77.v ± vii.6	58.5 ± 15.0	< 0.001
% > 75 years	68.4	xi.2	< 0.001
% Male	59.four	66.vi	NS
% Non-white	14.two	fifteen.7	NS
% Diabetes	35.five	34.3	NS
% High comorbidity	49.7	17.3	< 0.001
eGFR at stage v (mL/min/i.73 m^two)	13.ii ± 1.4	xiii.2 ± 1.4	NS

	Conservative	Dialysis	P-value
Number	155 (xviii%)	689 (82%)
Age at stage five (years)	77.5 ± seven.6	58.v ± 15.0	< 0.001
% > 75 years	68.4	11.2	< 0.001
% Male	59.4	66.half dozen	NS
% Non-white	14.2	xv.7	NS
% Diabetes	35.five	34.3	NS
% High comorbidity	49.7	17.3	< 0.001
eGFR at phase 5 (mL/min/1.73 mⁱⁱ)	13.two ± 1.4	xiii.ii ± one.4	NS

Of the 155 patients in the CM group, 29 (18.vii%) were surviving at terminal assay. Of the remaining 126 patients, 57 (45.2%) died with a last recorded eGFR < viii.22 mL/min/one.73 m² (median eGFR at outset of dialysis in elderly patients) and 69 (54.8%) had terminal recorded eGFR college than this. However, information technology is not possible to conclude that renal failure did not contribute to death in the latter group or fifty-fifty that at least some of these patients would not already have started dialysis had they chosen this selection.

Considering the whole group of 844 patients, median survival in Kaplan–Meier analysis was far superior in RRT patients than in those conservatively managed (67.ane vs 21.two months: P < 0.001: Figure 1). Median survival was also greater in those aged ≤ 75 years than in older patients (67.0 vs 28.5 months: P < 0.001), in those without high comorbidity compared to those with comorbidity (68.4 vs 25.1 months: P < 0.001) and in those without diabetes than in those with diabetes (63.9 vs 44.seven months: P < 0.001). Gender and ethnicity did not predictably influence survival. In the RRT group, there was improved median survival in patients aged < 75 years (69.half dozen vs 33.0 months: P < 0.001), in the absence of loftier comorbidity (72.v vs 33.0 months: P < 0.001) and in not-diabetics (74.4 vs 52.8 months: P < 0.001). Gender and ethnicity again did not influence survival. In contrast, in the conservatively managed grouping, patients > 75 years had improved median survival compared with younger patients (25.1 vs 15.5 months: P = 0.001), as did non-diabetics (24.iv vs 18.i months: P = 0.011). Although median survival was a little higher in patients without high comorbidity in this grouping (26.0 vs 17.four months), the difference was not statistically pregnant (P = 0.124). Women also had a slightly higher median survival than men (24.0 vs 19.5 months: P = 0.084). At that place were no ethnic differences.

Fig. ane

Kaplan–Meier survival curves from entry into stage 5 CKD for patients treated past RRT (north = 689) and by conservative kidney management (northward = 155).

Because all patients aged > 75 years (Tabular array ii and Effigy ii), those without high comorbidity had better survival when treated by RRT rather than past conservative means (36.8 vs 29.4 months: P = 0.03). However, patients in this historic period group with loftier comorbidity, treatment by RRT was associated with a smaller increase in median survival, of around 5 months, which was non statistically significant (Table 2 and Figure 2). Even within this elderly grouping, CM patients were significantly older than RRT patients (81.8 vs 79.3 years; P < 0.001). When all patients who reached stage 5 CKD aged > 75 years were analysed in a Cox proportional hazards model, afterward correction for historic period, diabetes, comorbidity, gender and ethnicity, RRT did non confer a significant survival advantage (Table 3 and Effigy 3).

Table 2

Median survival past Kaplan–Meier analysis of patients aged > 75 treated by conservative means or by dialysis, stratified past comorbidity group

		Number	Median	SE	95% CI		P-value
		Number	Median	SE	Lower bound	Upper bound	P-value
Low comorbidity	Dialysis	60	36.viii	8.iv	xx.4	53.ii	0.03
Low comorbidity	Conservative	52	29.4	3.7	22.two	36.6	0.03
Severe comorbidity	Dialysis	17	25.8	4.4	17.3	34.4	0.83
Severe comorbidity	Bourgeois	54	20.4	ii.4	15.7	25.2	0.83

		Number	Median	SE	95% CI		P-value
		Number	Median	SE	Lower spring	Upper bound	P-value
Low comorbidity	Dialysis	60	36.8	8.4	twenty.4	53.2	0.03
Low comorbidity	Conservative	52	29.4	three.seven	22.2	36.6	0.03
Severe comorbidity	Dialysis	17	25.8	4.iv	17.3	34.four	0.83
Severe comorbidity	Conservative	54	twenty.4	two.iv	15.7	25.2	0.83

Table ii

Median survival by Kaplan–Meier assay of patients anile > 75 treated by conservative means or by dialysis, stratified by comorbidity group

		Number	Median	SE	95% CI		P-value
		Number	Median	SE	Lower spring	Upper spring	P-value
Low comorbidity	Dialysis	60	36.8	viii.4	20.four	53.2	0.03
Low comorbidity	Conservative	52	29.4	three.7	22.2	36.6	0.03
Severe comorbidity	Dialysis	17	25.eight	four.4	17.3	34.4	0.83
Severe comorbidity	Conservative	54	20.4	2.4	xv.7	25.ii	0.83

		Number	Median	SE	95% CI		P-value
		Number	Median	SE	Lower jump	Upper spring	P-value
Low comorbidity	Dialysis	60	36.viii	8.4	20.4	53.ii	0.03
Low comorbidity	Bourgeois	52	29.iv	iii.7	22.two	36.6	0.03
Severe comorbidity	Dialysis	17	25.eight	4.four	17.3	34.4	0.83
Severe comorbidity	Conservative	54	20.iv	ii.iv	15.7	25.2	0.83

Fig. 2

Comparison of Kaplan–Meier survival curves by modality (RRT vs bourgeois kidney management) in patients > 75 years. The console on the left depicts the relationships in those with low comorbidity and that on the correct in those with high comorbidity.

Tabular array three

Cox proportional hazards model for survival in patients anile > 75. Increasing age, the presence of loftier comorbidity and male gender but non the modality (CM or RRT) are significant predictors of bloodshed in this grouping of patients. Numbers in foursquare brackets indicate the number of patients in each category

Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	95.0% CI for 60 minutes
Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	Lower	Upper
Modality (CM [77] vs RRT [106])	0.428	one.177	0.787	1.759
Age at stage v (years)	0.004	1.076	ane.024	ane.131
Comorbidity (high [71] vs low [112])	0.002	1.823	one.255	2.650
Diabetes (diabetic [48] compared with non-diabetic [135])	0.176	1.308	0.887	1.928
Gender (female [59] compared with male [124)	0.025	0.646	0.440	0.948
Ethnicity (non-white [12] compared with white [171])	0.806	i.111	0.479	2.577

Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	95.0% CI for HR
Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	Lower	Upper
Modality (CM [77] vs RRT [106])	0.428	1.177	0.787	1.759
Historic period at stage 5 (years)	0.004	1.076	1.024	1.131
Comorbidity (high [71] vs low [112])	0.002	one.823	1.255	2.650
Diabetes (diabetic [48] compared with non-diabetic [135])	0.176	1.308	0.887	ane.928
Gender (female [59] compared with male person [124)	0.025	0.646	0.440	0.948
Ethnicity (non-white [12] compared with white [171])	0.806	one.111	0.479	2.577

Table 3

Cox proportional hazards model for survival in patients aged > 75. Increasing historic period, the presence of high comorbidity and male person gender but non the modality (CM or RRT) are pregnant predictors of bloodshed in this grouping of patients. Numbers in foursquare brackets indicate the number of patients in each category

Chi square = 30.91 (P < 0.001)	P-value	Gamble ratio	95.0% CI for 60 minutes
Chi square = 30.91 (P < 0.001)	P-value	Gamble ratio	Lower	Upper
Modality (CM [77] vs RRT [106])	0.428	1.177	0.787	1.759
Age at phase five (years)	0.004	1.076	1.024	one.131
Comorbidity (high [71] vs low [112])	0.002	ane.823	one.255	2.650
Diabetes (diabetic [48] compared with not-diabetic [135])	0.176	1.308	0.887	1.928
Gender (female person [59] compared with male [124)	0.025	0.646	0.440	0.948
Ethnicity (not-white [12] compared with white [171])	0.806	one.111	0.479	2.577

Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	95.0% CI for Hr
Chi square = 30.91 (P < 0.001)	P-value	Hazard ratio	Lower	Upper
Modality (CM [77] vs RRT [106])	0.428	i.177	0.787	1.759
Age at stage 5 (years)	0.004	1.076	1.024	ane.131
Comorbidity (high [71] vs depression [112])	0.002	1.823	1.255	2.650
Diabetes (diabetic [48] compared with non-diabetic [135])	0.176	i.308	0.887	ane.928
Gender (female person [59] compared with male [124)	0.025	0.646	0.440	0.948
Ethnicity (non-white [12] compared with white [171])	0.806	1.111	0.479	two.577

Fig. 3

Cox proportional model survival bend of patients aged > 75 years—CM vs RRT—adjusted for age, gender, ethnicity, the presence of diabetes and the presence of high comorbidity. Median survival in RRT patients is better by < iv months, which is non statistically significant (P = 0.43).

In addition to the differences in age (81.eight ± iii.nine vs 68.iv ± v.i years), patients anile > 75 years in the conser@vatively managed grouping were less likely to take diabetes than younger patients and more likely to be white (Table iv). There were no significant differences between those > 75 years and younger patients with respect to gender distribution, the prevalence of high comorbidity and hateful eGFR at the beginning of the study.

Table iv

Comparison of demographic and clinical features in conservatively managed patients aged > 75 years and in those who were younger

	Age ≤ 75	Age > 75	P-value
Number	49 (31.6%)	106 (68.4%)
Age at stage 5 (years)	68.4 ± 5.1	81.8 ± 3.9	< 0.001
% Male person	53.1	63.5	NS
% Non-white	26.five	8.5	0.005
% Diabetic	51.0	28.three	0.007
% High comorbidity	46.9	fifty.9	NS
eGFR at phase 5 (mL/min/i.73 k^two)	13.0 ± 1.4	thirteen.3 ± 1.4	NS

	Historic period ≤ 75	Age > 75	P-value
Number	49 (31.6%)	106 (68.iv%)
Age at phase v (years)	68.four ± 5.1	81.8 ± 3.9	< 0.001
% Male	53.one	63.v	NS
% Non-white	26.5	viii.v	0.005
% Diabetic	51.0	28.3	0.007
% High comorbidity	46.9	50.9	NS
eGFR at stage 5 (mL/min/i.73 m²)	thirteen.0 ± 1.4	13.3 ± ane.4	NS

Table 4

Comparison of demographic and clinical features in conservatively managed patients anile > 75 years and in those who were younger

	Historic period ≤ 75	Age > 75	P-value
Number	49 (31.6%)	106 (68.4%)
Age at phase 5 (years)	68.4 ± 5.one	81.8 ± 3.9	< 0.001
% Male	53.i	63.v	NS
% Not-white	26.5	viii.five	0.005
% Diabetic	51.0	28.3	0.007
% High comorbidity	46.9	50.9	NS
eGFR at phase 5 (mL/min/one.73 k²)	13.0 ± ane.4	13.three ± one.iv	NS

	Age ≤ 75	Age > 75	P-value
Number	49 (31.6%)	106 (68.4%)
Age at stage v (years)	68.4 ± five.1	81.8 ± iii.9	< 0.001
% Male	53.i	63.5	NS
% Non-white	26.5	eight.5	0.005
% Diabetic	51.0	28.iii	0.007
% High comorbidity	46.ix	50.nine	NS
eGFR at stage 5 (mL/min/1.73 one thousand^two)	xiii.0 ± one.4	13.3 ± 1.four	NS

In a Cox proportional hazards model, the significant predictors of bloodshed in RRT patients were historic period—each decade increasing bloodshed chance past > 30%, the presence of high comorbidity—incurring over twice the risk compared to less comorbid patients and the presence of diabetes—associated with a 60% increased chance compared to non-diabetic patients (Table five). The findings were similar if a dichotomized age covariate (≤ 75 and > 75 years) was substituted for the continuous historic period covariate in the model, though the model'southward predictive power was slightly less (model non shown). Applying the same model in conservatively managed patients produced differing results. The pregnant predictors of mortality were age—mortality being more double in those anile < 75 years compared to older patients and gender—women having a 35% reduced adventure compared to men (Table vi). Presence of high comorbidity and diabetes both conferred higher gamble—though this did not attain statistical significance. The better survival of conservatively managed patients aged > 75 yeas, adjusted for gender, ethnicity, the presence of diabetes, the presence of high comorbidity and eGFR at the first of the study, is shown in Figure 4.

Table five

Cox proportional hazards model for survival in patients treated by dialysis. Increasing age, the presence of diabetes and the presence of high comorbidity are pregnant predictors of mortality in this group of patients. Numbers in square brackets indicate the number of patients in each category

Chi foursquare = 131 (P < 0.001)	P-value	Take a chance ratio	95% CI for HR
Chi foursquare = 131 (P < 0.001)	P-value	Take a chance ratio	Lower	Upper
Gender (female person [293] compared with male [551)	0.752	0.965	0.771	1.207
Ethnicity (non-white [132] compared with white [712])	0.261	one.201	0.873	1.651
Diabetes (diabetic [291] compared with not-diabetic [553])	0.000	ane.604	ane.293	one.990
Comorbidity (high [196] vs low [648])	<0.001	two.214	1.732	2.830
eGFR at phase v (mL/min/1.73 mⁱⁱ)	0.258	0.959	0.891	1.031
Age at phase 5 (years)	<0.001	i.033	1.024	1.043

Chi foursquare = 131 (P < 0.001)	P-value	Gamble ratio	95% CI for Hr
Chi foursquare = 131 (P < 0.001)	P-value	Gamble ratio	Lower	Upper
Gender (female person [293] compared with male [551)	0.752	0.965	0.771	i.207
Ethnicity (non-white [132] compared with white [712])	0.261	1.201	0.873	one.651
Diabetes (diabetic [291] compared with non-diabetic [553])	0.000	one.604	1.293	1.990
Comorbidity (high [196] vs low [648])	<0.001	two.214	1.732	2.830
eGFR at stage 5 (mL/min/i.73 g²)	0.258	0.959	0.891	1.031
Age at stage 5 (years)	<0.001	1.033	one.024	1.043

Table 5

Cox proportional hazards model for survival in patients treated by dialysis. Increasing age, the presence of diabetes and the presence of high comorbidity are significant predictors of bloodshed in this group of patients. Numbers in square brackets indicate the number of patients in each category

Chi square = 131 (P < 0.001)	P-value	Hazard ratio	95% CI for HR
Chi square = 131 (P < 0.001)	P-value	Hazard ratio	Lower	Upper
Gender (female person [293] compared with male person [551)	0.752	0.965	0.771	ane.207
Ethnicity (non-white [132] compared with white [712])	0.261	1.201	0.873	1.651
Diabetes (diabetic [291] compared with non-diabetic [553])	0.000	1.604	one.293	1.990
Comorbidity (high [196] vs depression [648])	<0.001	two.214	1.732	2.830
eGFR at stage 5 (mL/min/i.73 m^two)	0.258	0.959	0.891	1.031
Age at stage five (years)	<0.001	1.033	ane.024	1.043

Chi square = 131 (P < 0.001)	P-value	Hazard ratio	95% CI for 60 minutes
Chi square = 131 (P < 0.001)	P-value	Hazard ratio	Lower	Upper
Gender (female [293] compared with male [551)	0.752	0.965	0.771	1.207
Ethnicity (non-white [132] compared with white [712])	0.261	one.201	0.873	one.651
Diabetes (diabetic [291] compared with non-diabetic [553])	0.000	one.604	1.293	1.990
Comorbidity (loftier [196] vs low [648])	<0.001	2.214	i.732	two.830
eGFR at stage 5 (mL/min/1.73 1000^two)	0.258	0.959	0.891	1.031
Age at phase 5 (years)	<0.001	one.033	1.024	1.043

Table vi

Cox proportional hazards model for predictors of survival in patients treated by conservative management. Age ≤ 75 and male person gender are significantly associated with increased mortality in this grouping of patients

Chi square = 22 (P < 0.001)	P-values	Hazard ratio	95% CI for HR
Chi square = 22 (P < 0.001)	P-values	Hazard ratio	Lower	Upper
Gender (female [63] vs male [92])	0.026	0.648	0.442	0.949
Ethnicity (not-white [22] vs white [133])	0.824	1.062	0.627	ane.799
Diabetic [55] vs non-diabetic [100]	0.094	1.409	0.943	2.105
Comorbidity (high [77] vs low [78])	0.099	one.365	0.943	1.976
eGFR at stage 5 (mL/min/ane.73 m²)	0.252	0.923	0.804	i.059
Age > 75 (yep vs no)	0.009	0.574	0.379	0.869

Chi square = 22 (P < 0.001)	P-values	Hazard ratio	95% CI for 60 minutes
Chi square = 22 (P < 0.001)	P-values	Hazard ratio	Lower	Upper
Gender (female person [63] vs male [92])	0.026	0.648	0.442	0.949
Ethnicity (non-white [22] vs white [133])	0.824	ane.062	0.627	1.799
Diabetic [55] vs non-diabetic [100]	0.094	1.409	0.943	2.105
Comorbidity (high [77] vs low [78])	0.099	1.365	0.943	1.976
eGFR at phase five (mL/min/1.73 chiliad²)	0.252	0.923	0.804	i.059
Age > 75 (yes vs no)	0.009	0.574	0.379	0.869

Table 6

Chi square = 22 (P < 0.001)	P-values	Take chances ratio	95% CI for Hour
Chi square = 22 (P < 0.001)	P-values	Take chances ratio	Lower	Upper
Gender (female [63] vs male person [92])	0.026	0.648	0.442	0.949
Ethnicity (not-white [22] vs white [133])	0.824	ane.062	0.627	one.799
Diabetic [55] vs not-diabetic [100]	0.094	1.409	0.943	ii.105
Comorbidity (high [77] vs low [78])	0.099	1.365	0.943	ane.976
eGFR at stage 5 (mL/min/1.73 m²)	0.252	0.923	0.804	one.059
Age > 75 (yes vs no)	0.009	0.574	0.379	0.869

Chi square = 22 (P < 0.001)	P-values	Risk ratio	95% CI for Hour
Chi square = 22 (P < 0.001)	P-values	Risk ratio	Lower	Upper
Gender (female [63] vs male [92])	0.026	0.648	0.442	0.949
Ethnicity (not-white [22] vs white [133])	0.824	ane.062	0.627	1.799
Diabetic [55] vs non-diabetic [100]	0.094	ane.409	0.943	2.105
Comorbidity (high [77] vs low [78])	0.099	1.365	0.943	one.976
eGFR at stage 5 (mL/min/i.73 m²)	0.252	0.923	0.804	1.059
Historic period > 75 (aye vs no)	0.009	0.574	0.379	0.869

Fig. 4

Cox proportional model survival curve of conservatively managed patients aged > 75 years vs younger patients—adjusted for gender, ethnicity, the presence of diabetes, the presence of high comorbidity and eGFR at the start of the study. Survival of older patients is significantly better than that of younger patients (P = 0.009).

Word

For the vast majority of patients with ESRD, RRT provides a huge survival advantage. All the same, in those > 75 years of age, this reward may be restricted to those without loftier comorbidity. We found that elderly patients with high comorbidity treated by dialysis had a median survival that was only 5 months longer from entry into stage 5 CKD than patients who had undergone conservative kidney direction—a small proportion of whom outlived all those on RRT past a number of years (Figure 2). In fact, when corrected for age, gender and comorbidity (Table 3), patients aged > 75 years did not gain a significant survival advantage from RRT. This does non mean that dialysis will not be of do good for all elderly patients with ESRD. Clearly an individualized approach is necessary. RRT is likely to be beneficial in many patients especially those with low comorbidity and in those with chop-chop failing renal function. Conversely, CM may accept a office in those patients with high comorbidity and slowly declining renal function.

The predictors of survival in RRT and conservatively managed patients were also markedly different. Every bit might exist expected, in the RRT population, the independent predictors of increased mortality were increasing age, loftier comorbidity and the presence of diabetes. In the conservatively managed grouping, nevertheless, age > 75 years and female gender were both independent predictors of improved survival. The presence of high comorbidity and diabetes approached significance.

Why do older patients and females bear witness better survival in the CM grouping? In this written report, older patients were less likely to accept diabetes, but the prevalence of high comorbidity was similar to that in younger patients (Tabular array 4). In any example, both these factors were controlled for in the Cox model. We cannot exclude a role for gender difference in the prevalence of primary renal diseases in this population, for example renovascular disease is more prevalent in men, though the Cox model corrected for diabetes and presence of severe comorbidity including vascular disease. The proportion of not-whites was besides significantly lower in older patients (Tabular array four), merely ethnicity was not an independent predictor of survival. It may be that there are factors other than those featuring in our survival model that are involved in the choice of the conservative management pick, and which may be overrepresented in men and in younger patients, e.thou. rate of pass up of renal function, frailty, functional status, social support and depression. Alternatively, information technology may be that older patients tin can survive with less renal function than younger patients and women with less than men. Renal function declines progressively with increasing age [18], perhaps associated with decreased metabolic demand [xix], only there is conflicting evidence for significant gender differences in energy expenditure. Paul et al . found that total energy expenditure, physical activity expenditure and resting energy expenditure were significantly lower in women [20]. Other authors take suggested that these differences are abolished when corrected for trunk weight, though the validity of such normalization is debated [twenty,21]. Notwithstanding this, there are major gender differences in body composition and insulin resistance that may be relevant [21]. Females take as well been shown to take slightly higher iothalamate glomerular filtration rates corrected for body surface expanse than males at all ages, at to the lowest degree up to sixty years [22], but this is unlikely to be relevant to elderly patients with ESRD.

Precisely how long patients survive on conservative kidney management is difficult to judge since the reference point from which survival was measured has varied from study to study. Some studies have attempted to friction match conservatively managed patients with a comparable dialysis grouping whilst others report survival in the conservative grouping alone. In a previous original report, we assessed survival from a 'putative dialysis date' obtained by matching Cockcroft–Gault creatinine clearances in the conservatively managed group with those in the relevant dialysis group at dialysis initiation [10]. In that study, we found median survivals of half-dozen.3 months in conservatively managed patients and eight.three months in patients recommended for bourgeois treatment only opting for dialysis. Carson et al . took a similar arroyo, in ESRD patients aged > seventy years, and found a median survival of thirteen.9 months in the conservative grouping and 37.8 months in RRT patients, though infirmary-free survival was similar in both groups [13]. The groups were similar in terms of comorbidity, simply median age was eight years greater in the bourgeois group. In octogenarians, median survival was 28.9 months in patients undergoing dialysis and 8.9 months in those treated conservatively measured from engagement of the decision not to perform dialysis (Cockcroft–Gault creatinine clearance < 10 mL/min in all cases) [17]. The groups however, differed considerably with respect to social isolation, late referral, Karnofsky operation score and diabetic status. Murtagh et al . found survival from an eGFR of 15 mL/min to exist like at around 22 months in patients > 75 years with high comorbidity in the conservative and dialysed groups [12]. Ellam et al . institute that median patient survival on conservative management from the time of first known CKD stage 5 was 21 months [xv]. Wong found a median survival of ane.95 years in conservatively managed patients though some had non reached stage five at entry into the study [14]. Our finding of a median survival of 21 months for conservatively managed patients post-obit entry into phase 5 CKD is compatible with much of the data outlined above.

There are a number of drawbacks in our written report including its retrospective nature and the absenteeism of detail on patient characteristics such as Karnofsky performance score and frailty. This obliges circumspection in the interpretation of our results. These drawbacks however, are somewhat first by the size of the study, which is the largest currently bachelor, and the length of follow-upward. We too used a non-standard simplified comorbidity assessment derived from our previous piece of work [5]. Our main purpose in this was to identify a loftier-risk group using a score that reflected both the number and the severity of extra-renal comorbid conditions rather than merely a count of affected organs. Assignment to the high comorbidity cluster was a powerful predictor of mortality in the dialysis grouping. Nosotros think, therefore, this arroyo was justified. It should also be noted that our option criteria effectively excluded about patients who were referred tardily. Such patients represent > 25% of new starters on dialysis, and elderly, dependent patients are over-represented in this grouping [five,23]. The lack of time to counsel and plan in this setting may mean that patients start on dialysis past default, peradventure inappropriately. This is an of import effect that is non addressed past this written report.

Whilst our results contribute to the information that can guide patients in making treatment decisions, an individualized arroyo to conclusion making is mandatory. Thus, an elderly patient with high comorbidity and wearisome decline of renal function is likely to do good from conservative management; this may not exist an advisable recommendation for someone with no comorbidity or rapidly failing renal role. Survival figures can merely provide generalized information, and each patient should be counselled individually on his or her chances of benefiting from dialysis. Patients are free to change their treatment decisions and these demand to exist respected when planning care.

Our report has contributed to our understanding of prognosis in patients treated past conservative management. It has also demonstrated a survival advantage for the elderly (> 75 years) and for women on this modality, though the reasons for this are unclear. Conservative kidney management is a valid treatment option in selected patients, and our aversion to rationing should not dissuade us from rational treatment decisions. There is a famine of prospective work in this area. The little data we have on the quality of life of patients on this pathway is reassuring [16]. For many reasons, we are unlikely to acquire data from randomized studies in this area [24]. High-quality prospective observational studies of outcomes, including quality of life, are urgently required.

Disharmonize of interest statement. None declared.

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