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Globally, incident dialysis patients are getting older with substantial disease and treatment burden resulting in dialysis withdrawal and poor survival rates. More patients are opting for conservative kidney management (CKM) to improve quality of life without the burden of dialysis. We aim to study the trends of CKM and survival outcome in our pre-dialysis patients.
This is a retrospective observational study conducted in Hospital Selayang involving pre-dialysis patients opting for CKM referred to palliative care unit (PCU) from the inpatient and outpatient services in 2022. Relevant data was extracted from electronic medical records and statistical analysis was done using SPSS version 26.
There were 621 outpatient pre-dialysis patients in 2022, of which 69 (11.1%) opted for CKM. There were another 87 referrals to PCU from the inpatient services. Of the 156 patients who chose CKM, 120 (76.9%) were pre-dialysis patients and 36 (23.1%) dialysis patients for withdrawal (21 hemodialysis, 15 peritoneal dialysis). Inpatient referrals had statistically significant in-hospital death (63.3%, p=0.008), more hospitalisations (p<0.001) and decisions for CKM were predominantly made by surrogate (85%, p<0.001). They also had higher proportion of patients on time limited dialysis (61.1%, p=0.083) although not statistically significant. There were 17 of 120 (14.1%) pre-dialysis patients who converted to dialysis after PCU referral. The conversion cohort were younger (60.3 ± 12.0 vs 69.4 ± 10.5, p=0.002), had more on time limited dialysis (38.9% vs 9.8%, p=0.001), more hospitalisations (p=0.013), more episodes of fluid overload or uremia (p=0.001) and decisions were made by patients instead of surrogate (100%, p=0.047).
Pre-dialysis patients who opted for CKM had 31.6% mortality. Of those who converted to dialysis, mortality rate was not statistically significant at 30.7% compared to 49.3% without conversion (p=0.436). A Kaplan-Meier analysis showed significantly longer mean survival for outpatient compared to inpatient PCU referrals [20.1 months (95% CI 18.2-21.9) vs 14.3 months (95% CI 11.3-17.3) p=0.001]. 1 year survival for outpatient was 78.6% compared 57.4% for inpatient referrals (p = 0.001).
In conclusion, pre-dialysis patients opting for CKM referred early in outpatient setting had better survival. There was no significant difference in mortality rate amongst those who converted to dialysis. Extensive pre-dialysis discussions on goals of care and shared decision making is important to improve patients quality of life and therefore reduce recurrent hospitalisation.