title: Supportive Care: Comprehensive Conservative Care in End-Stage Kidney Disease.
abstract: Comprehensive conservative (nondialytic) kidney care is widely recognized and delivered but until recently, has not been clearly defined. We provide a clear definition of comprehensive conservative care. This includes interventions to delay progression of kidney disease and minimize complications as well as detailed communication, shared decision making, advance care planning, and psychologic and family support. It does not include dialysis. Limited epidemiologic evidence from Australia and Canada indicates that, for every new person diagnosed with ESRD who receives dialysis or transplant, there is one new person who is managed conservatively (either actively or not). For older patients (those >75 or 80 years old) who have higher levels of comorbidity (such as diabetes and heart disease) and poorer functional status, the survival advantage of dialysis may be limited, and comprehensive conservative management may be considered; however, robust comparative evidence remains limited. Considerations of symptoms, quality of life, and hospital-free days are as or sometimes more important for patients and families than survival. There is some evidence that communication about possible conservative management options is generally insufficient, even where comprehensive conservative care pathways are already established. Symptom control and the cost-effectiveness of interventions are addressed in the companion papers within this Moving Points in Nephrology series. There is almost no evidence about which models of care and which interventions might be most beneficial in this population; future research on these areas is much needed. Meanwhile, consistency in definition of comprehensive conservative care and basing interventions on existing evidence about survival, symptoms, quality of life, and experience will maximize patient-centered and holistic care.
authors: Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, United Kingdom.
authors: Fliss E M
authors: FEM
authors: Murtagh
authors: Department of Nephrology, Royal Free Hospital National Health Service Foundation Trust, London, United Kingdom.
authors: Aine
authors: A
authors: Burns
authors: Institut Universitaire de Recherche Clinique, EA2415, Epidémiologie, Biostatistiques et santé publique, Faculté de Médecine, Université de Montpellier, Montpellier, France.|Nephrology and Dialysis Department, Centre Hospitalier Universitaire de Nimes, Nimes, France.
authors: Olivier
authors: O
authors: Moranne
authors: National Health and Medical Research Centre Clinical Trials Centre, University of Sydney, Sydney, Australia; and.
authors: Rachael L
authors: RL
authors: Morton
authors: Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
authors: Saraladevi
authors: S
authors: Naicker
mesh_terms: D000072700:Conservative Treatment / Q000706:statistics & numerical data; D006760:Hospitalization; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D011788:Quality of Life; D015996:Survival Rate; D063189:Symptom Assessment
keywords: Advance Care Planning; Australia; Canada; Chronic; Comorbidity; Heart Diseases; Humans; Kidney Failure; Prevalence; Renal Insufficiency; chronic kidney disease; conservative care; diabetes mellitus; palliative care; patient-centered care; quality of life; renal dialysis; supportive care