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Table 1 Clinical considerations for discussions about dialysis versus conservative managementa

From: Treatment decisions for older adults with advanced chronic kidney disease

Clinical Issues Suggested Trackb Comments
Dialysisc Conservatived
Renal Function Trajectory (RFD)    RFD defined as rate of decline of a patient’s estimated GFR (eGFR) per yeare
Slow < 3 ml/min/1.73 m2 /yearf
 Low Comorbidityg  h Patients are unlikely to be faced with a dialysis decision, but if their RFD increases, or they have an AKI episode, they may be good candidates for chronic dialysis.
 High Comorbidityi   □□□ These patients are the most likely to remain in a conservative care track due to slow loss of renal function and high probability of death from comorbidity related issues.
Medium 3–5 ml/min/1.73 m2 /yearj
 Low Comorbidity ❍❍   Compared with patients who have a slow RFD, these patients are more likely to require dialysis, especially if starting from an eGFR close to 15 ml/min/1.73 m2 (see Fig. 2).
 High Comorbidityi   □□ Due to the relationship between faster RFD and worse survival [23, 36], these patients are likely to die before dialysis is required and therefore remain on a conservative track.
Fast >5 ml/min/1.73 m2 /yeark
 Low Comorbidity ❍❍❍   These patients are the most likely to require dialysis and should be offered all treatment modalities, including renal transplant [2].
 High Comorbidity   Likelihood of remaining in conservative track may be low for most patients. Patient and family input with emphasis on a patient’s treatment goals is critical (Fig. 1, Table 2). Short survival on dialysis likely.
Acute Kidney Injury (AKI    Defined as patients who have a sudden sustained serum creatinine increase e [3] and most often uses a serum creatinine of ≥ 2x baseline creatinine [51]. Dialysis may in many cases be initiated “early” (eGFR > 10 ml/min/1.73 m2), [50, 52,53,54] and eGFR may overestimate true GFR [7, 52].
 Low Comorbidity ❍❍   If patients have renal failure symptoms dialysis may be necessary. Preemptive dialysis, without a conventional dialysis indication, has not been shown to be beneficial [53, 54]. Recovery of renal function should be tracked [81, 82]
 High Comorbidity   □□ Non-dialysis management should be considered during joint decision discussions due to a predicted short survival after dialysis initiation. Surrogate decision makers may choose dialysis if patients have not expressed a desire for non-dialysis management [19].
  1. aThis table is meant as a framework for ongoing joint decision conversations with older adults, defined as age ≥ 75, with advanced CKD, eGFR <30 ml/min/1.73 m2. Rate of loss of renal function, a patient’s comorbidity level, and episodes of acute declines in kidney function relate to the potential need for a dialysis decision and the choice of dialysis versus conservative management
  2. bSuggested tracks are understood as choices that a patient may make with discussion and advice from the health care team. The tracks are meant to be flexible, since patients may have changes in rate of renal function loss, comorbidities, and may have single or multiple episode of acute renal failure as well as changes in their goals and priorities which may influence their desire to be managed with dialysis versus a conservative (non-dialytic) manner
  3. cUnless otherwise stated, dialysis modality is hemodialysis. There is no definitive data on comparative elderly patient survival with hemodialysis versus peritoneal dialysis. Issues regarding dialysis modality choice and consideration for renal transplantation are discussed by Berger, et al. [2]
  4. dThe conservative track is conservative management, which includes shared decision making, active symptom management, psychosocial and spiritual support, treatment options that focus on a patients priorities which may include a palliative approach with a primary emphasis on relief of a patient’s symptoms, with less monitoring and pharmacologic therapy [15,16,17,18,19,20,21]
  5. eRFD can be calculated using the arithmetic difference between first and last available eGFR or the first and last year’s average eGFR divided by the initial value [25,26,27]. Some limitations for this calculation include – non linear e GFR patterns, stability and increases of eGFR; episodes of acute renal failure are not considered [23, 24]
  6. fAvailable studies suggest that the majority of elderly advanced CKD patients have a slow loss of eGFR, < 3 ml/min/1.73 m2/year [25, 28,29,30]
  7. gMost clinicians would consider a minimum projected survival > 1 year for older adults with advanced CKD as low comorbidity. Several prognostic scores have been developed to predict which patients will require dialysis [34, 35, 38] and to predict post dialysis initiation survival [39,40,41,42,43,44,45,46], including an on line calculator (https://www.qxmd.com/calculate/calculator/3-month-mortality-in-incident-elderly-esrd-patients). The parameters used to predict short survival after dialysis initiation include: poor functional status (i.e., inability to transfer), nursing home residence, low serum albumin (<2.5 gm/dl), low body mass index (<18.5 kg/m2) significant heart failure (New York Heart Association grade 3, 4), severe peripheral vascular disease, dementia, and a negative response to the “surprise question” (would I be surprised if this patient died in the next twelve months?)
  8. hOne, two, three squares or circles are used to approximate the weight of the suggested approach for a patient to consider --a conservative or dialysis care track
  9. iMost clinicians would consider a projected survival of <3 months to represent high comorbidity but for some, a 6 month projected survival would qualify. An on-line calculator is available to identify patients with projected 3-month mortality (https://www.qxmd.com/calculate/calculator/3-month-mortality-in-incident-elderly-esrd-patients). Other prognostic scores can be used to help predict a high 3 and 6-month dialysis mortality [40, 43, 44, 46]. Additionally, the following situations may be considered for high comorbidity classification:
  10. A. Dialysis cannot be provided safely [19, 47]
  11. a. Patient needs to be restrained or heavily sedated to use his vascular access
  12. b. Patient unable to cooperate due to dementia
  13. c. Multiorgan failure with profound hypotension
  14. B. Incurable malignancy or other non-renal cause of imminent death [19].
  15. C. Older adults with ≥ 2 of the following conditions [47]
  16. a. High comorbidity score
  17. b. Significantly impaired functional status
  18. c. Severe chronic malnutrition (serum albumin <2.5 g/dL)
  19. d. Clinician’s response of “no” to surprise question -“I would not be surprised if the patients dies within the next year”
  20. D. Patient is dependent on artificial hydration and nutrition to survive
  21. jMedium rate of renal function loss is included for completeness and is not used in published accounts of RFD
  22. kA fast RFD has generally been reported for most patients who start dialysis [23, 25, 30, 48]