Older patients’ choices between dialysis and conservative kidney management

The incidence of kidney failure is greatest in those aged 65 years and over. Many within this population live with two or more long-term health conditions, and the majority will experience frailty. 

Individuals with end-stage kidney disease (ESKD) experience a significant healthcare burden, including polypharmacy, serial medical appointments and lifestyle changes. The burden of healthcare is likely to be greatest for people who receive in-centre haemodialysis, and yet in the UK, this is the most prevalent form of ESKD treatment for this older population. 

Most of those who start dialysis, either at a centre or at home, continue until they die. Transplantation is less common in this age group. Conservative kidney management (CKM), which focuses on managing their symptoms and maintaining quality of life without dialysis, is likely to be an equally valid option.

The relative ability of dialysis and CKM to improve survival and quality of life, however, is uncertain. The present qualitative study was designed to understand how older people with kidney failure, who have not started kidney replacement therapy, view the choice between dialysis and CKM. Semi-structured interviews were used to examine patients’ perceptions of the treatment options for kidney failure and how decisions between options were made.

Those receiving specialist chronic kidney disease (CKD) care were eligible to participate if they had an eGFR <15 mL/min/1.73 m² and were aged over 80 years, irrespective of comorbidity, or over 65 years if they had a Davies comorbidity score ≥2 or a WHO performance status score of ≥3. Participants were purposively sampled from three hospitals in England and one interview conducted with each. Recruitment was continued until no new major themes arose from analysis of the interviews.

Eight men and 7 women took part, with a median age of 81 years (range 65–90) and a median eGFR of 12 mL/min/1.73 m². All described their ethnicity as white British. Seven were preparing for in-centre haemodialysis, two for peritoneal dialysis and six for CKM. None were waiting for a transplant.

For most participants, being informed of their impending kidney failure was a seminal and intensely negative experience. For some, the shock they experienced suggested that the implications of declining kidney function had not been communicated. Others may have understood that kidney failure was a separate, more severe condition, rather than an advanced stage of CKD.

Three major themes were identified from the interviews. Theme 1, “do dialysis or die”, was the perspective that dialysis was needed to sustain life, and declining it was turning down a longer life. 

Theme 2, the “need” for dialysis, captured the feeling that many felt they had been told for years that they would eventually “have to” start dialysis. To some, it was a surprise that there were alternatives to haemodialysis. CKM was typically presented as a “do nothing” option, rather than an active choice.

Theme 3, “weighing-up quality and quantity of life”, reflected a universal assessment by participants of the positive and negative aspects of futures with and without dialysis. This allowed them to evaluate their anticipated treatment and compare it to the alternatives. The assumed extension to life needed to be of acceptable quality, and the ability to live independently was greatly valued. Participants considered dialysis to be unpleasant, with few anticipating that they would feel better after initiation.

Few participants appeared familiar with the uncertain survival benefits of dialysis. This ignorance, compounded by unfamiliarity with other treatment options, resulted in haemodialysis frequently being viewed as the inevitable default treatment for kidney failure. To facilitate optimal shared decision-making, clinicians should present treatment options for ESKD in a balanced manner, articulate uncertainty and support patients as they weigh up trade-offs between quality and quantity of life.

The full article can be read here.