
Patients with advanced chronic kidney disease who refuse dialysis can live for many years with improved mental health as well as stable physical health and quality of life until the end of their illness, according to research.
Researchers discovered, however, that several individuals used acute care services and that there were considerable discrepancies in end-of-life care access. More study is needed, according to the researchers, to improve outcomes in individuals who are not on dialysis.
"Previous systematic reviews and meta-analyses reflect only a small fraction of the patients who forego dialysis described in the literature and provide only a limited view of the clinical course of patients to guide ongoing management and anticipatory guidance to patients who have already decided that they will not pursue dialysis," Susan P. Y. Wong, MD, MS, and colleagues wrote. "We conducted a systematic review of longitudinal studies reporting survival, use of health care resources, quality of life, and end-of-life care of patients with advanced CKD who did not pursue dialysis to support a deeper understanding of the long-term outcomes of patients with advanced CKD who do not pursue dialysis."
The systematic analysis included 41 cohort studies and 5,102 adults without dialysis who had advanced kidney disease. Using a standardized data extraction form, researchers collected baseline data as well as patterns of end-of-life care for patients who died during follow-up. Researchers chose to synthesize the reported results rather than meta-analyze the data.
Based on the baseline mean eGFR range of 7 mL/min/1.73 m2 to 18 mL/min/1.73 m2, researchers discovered a range of medial survival of 1 to 41 months across the 34 studies that provided information on survival. Patients had one to two hospital admissions, six to sixteen days in the hospital, seven to eight clinical visits, and two ED visits every year, according to the analysis.
Researchers observed enhanced mental well-being, as well as sustained physical well-being and overall quality of life, in patients throughout the course of 8 to 24 months.
Researchers discovered that 20 percent to 76 percent of patients who died before follow-ups enrolled in hospice, 27 percent to 68 percent died in a hospital, and 12 percent to 71 percent died at home. Similarly, during their final month of life, 57 percent to 76 percent of patients were hospitalized, and 4 percent to 47 percent got an invasive treatment.
More research is needed, according to the researchers, to improve the outcomes of individuals who do not utilize dialysis. "Our findings refute the widely held belief that for many patients with severe CKD, the only alternative to dialysis is death or no care." Despite the cohorts' late ages and high comorbidity, most patients in this study lived for several years after deciding to forego dialysis. "We also discovered that, until late in the illness course, mental well-being improved over time, whereas physical well-being and overall quality of life remained mostly steady," Wong and colleagues noted. "Not only do these data show that conservative renal treatment could be a feasible and beneficial therapeutic option to dialysis, but they also emphasize the benefits of its multidisciplinary approach to care and aggressive symptom management."
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