title: CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life.
abstract: OBJECTIVE
  Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis.
  
  
  METHODS
  In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic.
  
  
  RESULTS
  Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL.
  
  
  CONCLUSIONS
  Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.
authors.affiliation: Department of Renal Medicine, St. George Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia; and mbrown@unsw.edu.au.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Brown
authors.affiliation: Department of Renal Medicine, St. George Hospital, Sydney, Australia;
authors.forename: Gemma K
authors.initials: GK
authors.lastname: Collett
authors.affiliation: Department of Renal Medicine, St. George Hospital, Sydney, Australia;
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Josland
authors.affiliation: George Institute for Global Health, Sydney, Australia.
authors.forename: Celine
authors.initials: C
authors.lastname: Foote
authors.affiliation: George Institute for Global Health, Sydney, Australia.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Li
authors.affiliation: Department of Renal Medicine, St. George Hospital, Sydney, Australia;
authors.forename: Frank P
authors.initials: FP
authors.lastname: Brennan
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000523:psychology*; D002755:Choice Behavior; D017281:Cost of Illness; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D010166:Palliative Care; D010358:Patient Participation; D010361:Patients / Q000523:psychology*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011788:Quality of Life; D006435:Renal Dialysis / Q000009:adverse effects / Q000523:psychology*; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000523:psychology / Q000628:therapy*; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016312:Treatment Refusal
keywords: dialysis; elderly patients; palliative care; renal supportive care