Dialysis Initiation in Chronic Kidney Disease: Weighing Survival Benefits Against Increased Inpatient Care

Centrala begrepp

Older patients with advanced chronic kidney disease who initiate dialysis within a month may experience modest survival benefits, but this comes at the cost of spending more time in inpatient care settings compared to those who continue medical management.

Sammanfattning

The study examined the trade-offs between initiating dialysis and continuing medical management for older adults with advanced chronic kidney disease (CKD). Key findings:

• Patients who started dialysis within 30 days had a mean survival of 770 days, compared to 761 days for those who continued medical management - a difference of just 9.3 days.
• However, the dialysis group spent 13.6 fewer days at home (not receiving inpatient care) compared to the medical management group.
• In the 80+ age group, starting dialysis was associated with 60 days longer survival but 12.9 fewer days at home.
• In the 65-79 age group, the medical management group actually had 16.6 days longer survival than the dialysis group, while still spending 14.4 fewer days at home.
• The authors conclude that decisions to start dialysis should carefully consider the trade-off between potential survival benefits and increased time spent in inpatient settings, in the context of the patient's values and goals.

Statistik

"Patients who started dialysis within a month had a mean survival of 770 vs 761 days among the group choosing medical management, for a mean difference of just 9.3 days."
"The group that started dialysis had a mean of 13.6 fewer days at home, defined as not receiving inpatient care in a hospital, skilled-nursing facility, nursing home, or rehabilitation facility, vs medical management."
"Among those aged 80 years or older, starting dialysis within a month was associated with a mean of 60 days longer survival compared with medical management but 12.9 fewer days at home."
"Among adults aged 65-79 years, the survival time in fact favored those continuing medical management by a mean of 16.6 days, while those starting dialysis still spent 14.4 fewer days at home."

Citat

"Decisions to start dialysis at this level of kidney function should consider the clinical factors that affect this trade-off and whether the expected outcomes of starting dialysis align with an individual's values and goals."
"Widely referenced estimates of survival after dialysis initiation are misleading to use in shared decision-making because these figures underestimate early mortality and run the risk of misattributing how long patients live to a beneficial effect of dialysis treatment."
"In the 65-80 age group, our findings are consistent with the IDEAL trial and suggest that it's reasonable to defer dialysis until patients have more advanced symptoms and/or lower kidney function."

Viktiga insikter från

Dialysis Benefits in CKD Come With Trade-Offs

by Nancy A. Mel... på www.medscape.com 08-20-2024

https://www.medscape.com/viewarticle/dialysis-benefits-chronic-kidney-failure-come-trade-offs-2024a1000f8q

Djupare frågor

What other factors, beyond age and disease severity, should be considered when weighing the decision to initiate dialysis versus continuing medical management for patients with advanced CKD?

In addition to age and disease severity, several other factors should be taken into consideration when deciding whether to start dialysis or continue with medical management for patients with advanced CKD. These factors include the patient's overall health status, comorbidities, functional status, quality of life, personal values and preferences, social support system, cognitive function, and ability to adhere to complex treatment regimens. It is essential to assess the patient's goals of care, understanding of the treatment options, and willingness to undergo dialysis, as well as their understanding of the potential risks and benefits associated with dialysis initiation.

How can healthcare providers better communicate the potential trade-offs of dialysis initiation to patients and their families to ensure informed decision-making?

Healthcare providers can improve communication with patients and their families regarding the trade-offs of dialysis initiation by engaging in shared decision-making processes that involve open and honest discussions about the risks, benefits, and alternatives to dialysis. Providers should ensure that patients have a clear understanding of their prognosis, treatment options, potential outcomes, and the impact of dialysis on their quality of life. Using decision aids, educational materials, and visual aids can help facilitate discussions and enhance patient understanding. It is crucial to address patients' values, preferences, and goals of care, while also considering their cultural beliefs, spiritual needs, and emotional well-being. Providing ample time for patients to ask questions, express concerns, and make informed decisions is essential in promoting patient-centered care.

What innovative dialysis methods or alternative treatments are being developed to improve outcomes and reduce the burden of inpatient care for patients with advanced CKD?

Innovative dialysis methods and alternative treatments are being developed to enhance outcomes and reduce the burden of inpatient care for patients with advanced CKD. Some of these approaches include home dialysis modalities such as peritoneal dialysis and home hemodialysis, which offer greater flexibility, convenience, and autonomy for patients. Technological advancements in wearable and portable dialysis devices are being explored to improve access to dialysis and enable patients to receive treatment in non-traditional settings. Additionally, research is focusing on the development of bioengineered kidneys, implantable artificial kidneys, and regenerative medicine approaches to provide long-term solutions for kidney failure. Personalized medicine strategies, precision nephrology, and targeted therapies are also being investigated to tailor treatment plans to individual patient needs and optimize outcomes while minimizing the need for frequent hospitalizations. These innovative approaches aim to transform the landscape of kidney care and improve the overall well-being of patients with advanced CKD.