Introduction:
People with kidney failure face significantly higher risk of death and the potential for a major symptom burden. For many individuals, medical management without dialysis is an appropriate treatment decision, particularly when supported by a dedicated renal supportive care service (RSC). These services aim to promote a patient-centred approach incorporating nephrology principles with those of palliative care, including systematic symptom management, prognostication and advance care planning. Due to the inherent unpredictability of kidney failure, however, it can be difficult to counsel people about what to expect for their future health trajectory. To aid these discussions, we sought to provide a more comprehensive exploration of survival and symptom burden for people with medical management of kidney failure without dialysis, under the care of an RSC team, than has previously been reported.
Methods:
We conducted a retrospective cohort study of people with an estimated glomerular filtration rate (eGFR) ≤15mL/min/1.72m2 under the care of our RSC team for medical management without dialysis. Routine care databases were used to collect baseline demographics, comorbidities, pathology testing, date of death; and symptom burden assessed through the Integrated Patient Outcome Scale-Renal (IPOS-Renal) scoring system. Median survival was assessed according to pre-determined baseline predictors through Cox regression modelling.
Results:
The cohort included 223 people receiving care between January 2016 and April 2023. The median age was 84 (IQR: 77-87) and median survival was 452 days (95% confidence interval [CI] 351-552). People with eGFR 11-15mL/min/1.73m2 at entry into the RSC team cohort had a median survival of 517 days (95% CI 406-623), patients with eGFR 6-10mL/min/1.73m2 at entry had a median survival of 260 days (95% CI 138-382) and people with eGFR ≤5mL/min/1.73m2 at entry had a median survival of 61 days (95% CI 46-107). There was no statistically significant difference in survival according to the presence versus absence of ischaemic heart disease (434 days vs 475 days, p=0.3), heart failure (367 days vs 538 days, p=0.17), peripheral vascular disease (545 days vs 445 days, p=0.297), stroke (472 days vs 452 days, p=0.47), diabetes (490 days vs 423 days, p=0.53) or chronic liver disease (490 days vs 445 days, p=0.74). Baseline living situation was significantly associated with survival, with people living independently at home having a higher median survival (538 days), compared to assisted living at home (356 days) or living in nursing home (232 days) (p<0.05). At year one the most prevalent symptoms reported were weakness at 60% and poor mobility at 57% with median “moderate” severity, followed by pruritus at 33% at “moderate” intensity. At year two, weakness and poor mobility remained the most prevalent at 64% and 45% respectively with a median “moderate” severity, followed by pain at 29% at “moderate” intensity. There was no association between delta eGFR and median IPOS scores (p=0.75), or between total IPOS scores and survival (p=0.25).
Conclusions:
The study provided valuable insights into average life expectancy with kidney failure managed without dialysis, the significance of baseline living situation in anticipating life expectancy, and the potential symptom burden, to help guide clinicians and patients facing the uncertainty of this clinical scenario.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.